Healthcare Provider Details

I. General information

NPI: 1487891545
Provider Name (Legal Business Name): MARISA ANN BROWN PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2009
Last Update Date: 03/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 WATERVILLE RD
AVON CT
06001
US

IV. Provider business mailing address

15 ORANGE ST #215
NEW HAVEN CT
06510
US

V. Phone/Fax

Practice location:
  • Phone: 860-284-0182
  • Fax:
Mailing address:
  • Phone: 480-225-4444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number003226
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number6486
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: