Provider Demographics
NPI:1013416320
Name:BROSHIOUS, TAMMY JO (CDCA)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:JO
Last Name:BROSHIOUS
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-4259
Mailing Address - Country:US
Mailing Address - Phone:419-334-3431
Mailing Address - Fax:419-334-4230
Practice Address - Street 1:512 E STATE ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-4259
Practice Address - Country:US
Practice Address - Phone:419-334-3431
Practice Address - Fax:419-334-4230
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-02
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH060222101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)