Healthcare Provider Details

I. General information

NPI: 1265807515
Provider Name (Legal Business Name): GARRY BROWN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2015
Last Update Date: 02/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2611 WAYNE AVE BLDG 61
DAYTON OH
45420
US

IV. Provider business mailing address

2611 WAYNE AVE BLDG 61
DAYTON OH
45420-1833
US

V. Phone/Fax

Practice location:
  • Phone: 704-507-3675
  • Fax:
Mailing address:
  • Phone: 704-507-3675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: