Healthcare Provider Details

I. General information

NPI: 1922411776
Provider Name (Legal Business Name): STACEY BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2014
Last Update Date: 06/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 HURLBUT ST
PASADENA CA
91105-4025
US

IV. Provider business mailing address

696 E PINE ST
ALTADENA CA
91001-1984
US

V. Phone/Fax

Practice location:
  • Phone: 626-441-4221
  • Fax:
Mailing address:
  • Phone: 626-421-0161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: