Healthcare Provider Details

I. General information

NPI: 1295015428
Provider Name (Legal Business Name): CHARLES BROWN LPC, CAADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2011
Last Update Date: 08/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 BALL AVE NE
GRAND RAPIDS MI
49505-5904
US

IV. Provider business mailing address

1115 BALL AVE NE
GRAND RAPIDS MI
49505-5904
US

V. Phone/Fax

Practice location:
  • Phone: 616-456-9124
  • Fax: 616-774-2173
Mailing address:
  • Phone: 616-456-9124
  • Fax: 616-774-2173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401012389
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: