Healthcare Provider Details

I. General information

NPI: 1831709773
Provider Name (Legal Business Name): CARROLL TAYLOR BROWN III PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2020
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

652 PETALUMA AVE STE H
SEBASTOPOL CA
95472-4266
US

IV. Provider business mailing address

468 STOW AVE APT 3
OAKLAND CA
94606-1159
US

V. Phone/Fax

Practice location:
  • Phone: 707-823-3166
  • Fax: 707-869-8170
Mailing address:
  • Phone: 510-934-2805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number95202301
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95018200
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: