Healthcare Provider Details

I. General information

NPI: 1144110776
Provider Name (Legal Business Name): BRODUS LEE WICKS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2025
Last Update Date: 07/07/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 MARTIN LUTHER KING DR E
CINCINNATI OH
45219-2581
US

IV. Provider business mailing address

311 MARTIN LUTHER KING DR E
CINCINNATI OH
45219-2581
US

V. Phone/Fax

Practice location:
  • Phone: 513-475-5300
  • Fax:
Mailing address:
  • Phone: 513-475-5300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: