Provider Demographics
NPI:1649937681
Name:BROCKMAN, BLAINE PAUL
Entity type:Individual
Prefix:
First Name:BLAINE
Middle Name:PAUL
Last Name:BROCKMAN
Suffix:
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 1:765 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:WEST JEFFERSON
Mailing Address - State:OH
Mailing Address - Zip Code:43162-9587
Mailing Address - Country:US
Mailing Address - Phone:614-296-6391
Mailing Address - Fax:
Practice Address - Street 1:765 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:WEST JEFFERSON
Practice Address - State:OH
Practice Address - Zip Code:43162-9587
Practice Address - Country:US
Practice Address - Phone:614-296-6391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-24
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional