Healthcare Provider Details

I. General information

NPI: 1710121116
Provider Name (Legal Business Name): CHAD JOSEPH BROWN LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2009
Last Update Date: 02/12/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4160 24TH AVE S STE 102
FARGO ND
58104-9038
US

IV. Provider business mailing address

4160 24TH AVE S STE 102
FARGO ND
58104-9038
US

V. Phone/Fax

Practice location:
  • Phone: 701-941-0175
  • Fax: 701-941-3001
Mailing address:
  • Phone: 701-941-0175
  • Fax: 701-941-3001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number18662
License Number StateMN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier19311
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: