Healthcare Provider Details

I. General information

NPI: 1295961852
Provider Name (Legal Business Name): STACEY MCKINNIE BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2009
Last Update Date: 04/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3960 WALNUT DR
EUREKA CA
95503-8938
US

IV. Provider business mailing address

7200 SKYWAY
PARADISE CA
95969-3280
US

V. Phone/Fax

Practice location:
  • Phone: 707-268-8722
  • Fax: 707-268-0218
Mailing address:
  • Phone: 530-872-2103
  • Fax: 530-872-7784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: