Healthcare Provider Details

I. General information

NPI: 1194552596
Provider Name (Legal Business Name): JAMES WILLIS BROWN R1578750924
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2024
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23701 E EAST FORK RD
AZUSA CA
91702-1477
US

IV. Provider business mailing address

23701 E EAST FORK RD
AZUSA CA
91702-1477
US

V. Phone/Fax

Practice location:
  • Phone: 626-910-1202
  • Fax:
Mailing address:
  • Phone: 626-910-1202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1578750924
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: