Healthcare Provider Details

I. General information

NPI: 1245710367
Provider Name (Legal Business Name): ETTA KEMYATA BROWN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2018
Last Update Date: 07/09/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 E 70TH ST STE 201
SHREVEPORT LA
71105-5332
US

IV. Provider business mailing address

2306 VILLAGGIO BLVD.
BOSSIER CITY LA
71111-7459
US

V. Phone/Fax

Practice location:
  • Phone: 318-751-9098
  • Fax:
Mailing address:
  • Phone: 601-698-4172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number84782
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: