Healthcare Provider Details

I. General information

NPI: 1790550499
Provider Name (Legal Business Name): CAROLINE OLIVIA BROWN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2023
Last Update Date: 11/22/2023
Certification Date: 11/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S 11TH AVE POCATELLO STE 203
POCATELLO ID
83201
US

IV. Provider business mailing address

1215 S 4TH AVE
POCATELLO ID
83201
US

V. Phone/Fax

Practice location:
  • Phone: 208-346-7500
  • Fax:
Mailing address:
  • Phone: 240-727-7270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-8703
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: