Healthcare Provider Details

I. General information

NPI: 1669920856
Provider Name (Legal Business Name): THEODORE BROWN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2016
Last Update Date: 09/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11301 WILSHIRE BLVD
LOS ANGELES CA
90073-1003
US

IV. Provider business mailing address

11301 WILSHIRE BLVD
LOS ANGELES CA
90073-1003
US

V. Phone/Fax

Practice location:
  • Phone: 310-927-2173
  • Fax:
Mailing address:
  • Phone: 310-927-2173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number35653
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: