Provider Demographics
NPI:1508929415
Name:BRUBAKER, DONALD R (LISW)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:R
Last Name:BRUBAKER
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1037 W. MARKET STREET
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805
Mailing Address - Country:US
Mailing Address - Phone:419-222-5077
Mailing Address - Fax:419-228-5343
Practice Address - Street 1:1037 W. MARKET STREET
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805
Practice Address - Country:US
Practice Address - Phone:419-222-5077
Practice Address - Fax:419-228-5343
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI00011201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHBRSW24422Medicare ID - Type Unspecified
P49291Medicare UPIN