Basic Information
| Provider Information | |||||||||
| NPI: | 1346618063 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROCKMAN | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | LISW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 424 WARDS CORNER RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451406966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135767700 | ||||||||
| FaxNumber: | 5135761020 | ||||||||
| Practice Location | |||||||||
| Address1: | 1231 COLUMBUS AVE UNIT A1 | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450368196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136954495 | ||||||||
| FaxNumber: | 5132281236 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2015 | ||||||||
| LastUpdateDate: | 11/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | I1451226 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 0165638 | 05 | OH | MEDICAID |