Provider Demographics
NPI:1356102917
Name:BRABHAM, TYREE SR
Entity type:Individual
Prefix:MR
First Name:TYREE
Middle Name:
Last Name:BRABHAM
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 E SOMERVILLE AVE # 1
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-3012
Mailing Address - Country:US
Mailing Address - Phone:267-562-3409
Mailing Address - Fax:
Practice Address - Street 1:516 MARKET ST APT D1
Practice Address - Street 2:
Practice Address - City:MARCUS HOOK
Practice Address - State:PA
Practice Address - Zip Code:19061-4539
Practice Address - Country:US
Practice Address - Phone:267-562-3409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)