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General NPI Number Information
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NPI Number | 1346618063
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Entity Type | Individual
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Provider Name | THERESA A BROCKMAN LISW
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Gender | Female
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Dates
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Enumeration Date | 09/11/2015
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Last Update Date | 11/19/2021
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Provider Practice Location Address
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Address Line | 1231 COLUMBUS AVE UNIT A1
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City | LEBANON
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State | OH
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Zip | 45036-8196
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Country | US
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Telephone | 513-695-4495
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Fax | 513-228-1236
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Provider Business Mailing Address
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Address Line | 424 WARDS CORNER RD STE 200
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City | LOVELAND
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State | OH
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Zip | 45140-6966
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Country | US
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Telephone | 513-576-7700
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Fax | 513-576-1020
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | I1451226
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License Number State | OH
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