Healthcare Provider Details

I. General information

NPI: 1760052724
Provider Name (Legal Business Name): MR. TIMOTHY MORRIS BRUBAKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 01/06/2023
Certification Date: 01/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 MARTINEL DR
KENT OH
44240-4380
US

IV. Provider business mailing address

53 W RANDY ST
NEW FRANKLIN OH
44203-4822
US

V. Phone/Fax

Practice location:
  • Phone: 330-673-6339
  • Fax:
Mailing address:
  • Phone: 330-603-6229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.2204756
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: