Healthcare Provider Details

I. General information

NPI: 1811526924
Provider Name (Legal Business Name): BROOKE REIDY PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 08/20/2020
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BURNET AVE
CINCINNATI OH
45229-3026
US

IV. Provider business mailing address

3333 BURNET AVE # MLC7039
CINCINNATI OH
45229-3026
US

V. Phone/Fax

Practice location:
  • Phone: 513-803-2176
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberP.08037
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: