MEDICARE: DR. TY BRUMBACK PHD

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	103T00000X	Psychologist	P.08007	OH
2	103TA0400X	Addiction (Substance Use Disorder) Psychologist	P.08007	OH
3	103TB0200X	Cognitive & Behavioral Psychologist	P.08007	OH
4	103TH0100X	Health Service Psychologist	P.08007	OH
5	103TC0700X	Clinical Psychologist	P.08007	OH

General Provider Information

NPI Number	:	1316566474
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TY BRUMBACK PHD

Provider Business Mailing Address
First Line	:	7060 JEANNIE AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45230-4031
Country	:	US
Telephone Number	:	859-572-1484
Fax Number	:

Provider Business Practice Location Address
First Line	:	3380 ERIE AVE STE 202
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45208-1626
Country	:	US
Telephone Number	:	513-400-5905
Fax Number	:

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

Provider Enumeration Date	:	04/09/2020
Last Update Date	:	04/09/2020

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