Healthcare Provider Details

I. General information

NPI: 1023780020
Provider Name (Legal Business Name): VICTORIA BROXHOLM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2021
Last Update Date: 01/09/2024
Certification Date: 01/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 E 22ND ST
CLEVELAND OH
44115-3202
US

IV. Provider business mailing address

2525 E 22ND ST
CLEVELAND OH
44115-3202
US

V. Phone/Fax

Practice location:
  • Phone: 216-932-2800
  • Fax:
Mailing address:
  • Phone: 216-932-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-60246
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-81319
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: