Provider Demographics
NPI:1780107417
Name:BRUMBACK, EVYN
Entity type:Individual
Prefix:
First Name:EVYN
Middle Name:
Last Name:BRUMBACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EVYN
Other - Middle Name:TAYLOR
Other - Last Name:KEMPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1471 TWILIGHT TRL STE A
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601-8497
Mailing Address - Country:US
Mailing Address - Phone:067-776-1450
Mailing Address - Fax:502-352-2967
Practice Address - Street 1:1471 TWILIGHT TRL STE A
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601
Practice Address - Country:US
Practice Address - Phone:502-320-3128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist