Provider Demographics
NPI:1225572878
Name:BRUMMITT, MIKE D (LICDC-LISW)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:D
Last Name:BRUMMITT
Suffix:
Gender:M
Credentials:LICDC-LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4343 CLIFTON AVE
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44055-3077
Mailing Address - Country:US
Mailing Address - Phone:216-881-7882
Mailing Address - Fax:
Practice Address - Street 1:6140 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-3821
Practice Address - Country:US
Practice Address - Phone:440-233-7232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-15
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.20024021041C0700X
OHLICDC.161314101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical