Basic Information
| Provider Information | |||||||||
| NPI: | 1801495478 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BREMKE | ||||||||
| FirstName: | TAYLOR | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | QMHS CMS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 434 EASTLAND RD | ||||||||
| Address2: | |||||||||
| City: | BEREA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440171217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402342006 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2173 N RIDGE RD E STE E | ||||||||
| Address2: | |||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440553400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402608300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2020 | ||||||||
| LastUpdateDate: | 10/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | OH | N | Other Service Providers | Case Manager/Care Coordinator | 172V00000X | OH | Y | Other Service Providers | Community Health Worker |
No ID Information.