Provider Demographics
NPI:1962941757
Name:BRUMBAUGH, MARTHA I (CLINICAL SOCIAL WORK)
Entity type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:
Last Name:BRUMBAUGH
Suffix:I
Gender:F
Credentials:CLINICAL SOCIAL WORK
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311-1619
Mailing Address - Country:US
Mailing Address - Phone:937-599-1975
Mailing Address - Fax:
Practice Address - Street 1:118 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:BELLEFONTAINE
Practice Address - State:OH
Practice Address - Zip Code:43311-1619
Practice Address - Country:US
Practice Address - Phone:937-465-8065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-14
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS1500988104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker