Healthcare Provider Details

I. General information

NPI: 1235479494
Provider Name (Legal Business Name): BRENDA KROSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2013
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 W MAIN ST
FAIRBORN OH
45324-5037
US

IV. Provider business mailing address

3103 DIXIE HWY
HAMILTON OH
45015-1653
US

V. Phone/Fax

Practice location:
  • Phone: 937-281-4673
  • Fax: 937-318-1120
Mailing address:
  • Phone: 513-892-4673
  • Fax: 513-737-1107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDC 081183-3
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCS.00000015
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberS.0701012
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.081183
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: