Provider Demographics
NPI:1235520263
Name:MCBROOM, EVAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:
Last Name:MCBROOM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8040 CORPORATE CIR
Mailing Address - Street 2:SUITE #4
Mailing Address - City:NORTH ROYALTON
Mailing Address - State:OH
Mailing Address - Zip Code:44133-1282
Mailing Address - Country:US
Mailing Address - Phone:419-704-4769
Mailing Address - Fax:
Practice Address - Street 1:8040 CORPORATE CIR
Practice Address - Street 2:SUITE #4
Practice Address - City:NORTH ROYALTON
Practice Address - State:OH
Practice Address - Zip Code:44133-1282
Practice Address - Country:US
Practice Address - Phone:419-704-4769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-12
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7272103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical