Healthcare Provider Details

I. General information

NPI: 1104950310
Provider Name (Legal Business Name): HEATHER RENE BROWN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 10/06/2024
Certification Date: 10/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1138 E 37TH ST
SAN BERNARDINO CA
92404-1816
US

IV. Provider business mailing address

PO BOX 18
LOMA LINDA CA
92354-0018
US

V. Phone/Fax

Practice location:
  • Phone: 909-809-7831
  • Fax:
Mailing address:
  • Phone: 909-809-7831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW18018
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number30317
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number76753
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number101538
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: