MEDICARE: DR. EVAN MCBROOM PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	7272	OH

General Provider Information

NPI Number	:	1235520263
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EVAN MCBROOM PH.D.

Provider Business Mailing Address
First Line	:	8040 CORPORATE CIR
Second Line	:	SUITE #4
City	:	NORTH ROYALTON
State	:	OH
Zip	:	44133-1282
Country	:	US
Telephone Number	:	419-704-4769
Fax Number	:

Provider Business Practice Location Address
First Line	:	8040 CORPORATE CIR
Second Line	:	SUITE #4
City	:	NORTH ROYALTON
State	:	OH
Zip	:	44133-1282
Country	:	US
Telephone Number	:	419-704-4769
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/12/2015
Last Update Date	:	02/12/2015

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