1255455267 NPI number — MR. WILLARD WISHARD BROWN MA PSYCHOLOGY

Table of content: MR. WILLARD WISHARD BROWN MA PSYCHOLOGY (NPI 1255455267)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255455267 NPI number — MR. WILLARD WISHARD BROWN MA PSYCHOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROWN
Provider First Name:
WILLARD
Provider Middle Name:
WISHARD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MA PSYCHOLOGY
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255455267
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
339 TRIPLE CREEK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EFLAND
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27243-9573
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-304-5670
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
339 TRIPLE CREEK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EFLAND
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27243-9573
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-304-5670
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
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Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6111989 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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