Provider Demographics
NPI:1316566474
Name:BRUMBACK, TY (PHD)
Entity Type:Individual
Prefix:DR
First Name:TY
Middle Name:
Last Name:BRUMBACK
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 1:7060 JEANNIE AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45230-4031
Mailing Address - Country:US
Mailing Address - Phone:859-572-1484
Mailing Address - Fax:
Practice Address - Street 1:3380 ERIE AVE STE 202
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45208-1626
Practice Address - Country:US
Practice Address - Phone:513-400-5905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHP.08007103T00000X, 103TA0400X, 103TB0200X, 103TH0100X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service