Healthcare Provider Details

I. General information

NPI: 1902650443
Provider Name (Legal Business Name): DEDRA BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2024
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2345 DORR ST
TOLEDO OH
43607-3423
US

IV. Provider business mailing address

2345 DORR ST
TOLEDO OH
43607-3423
US

V. Phone/Fax

Practice location:
  • Phone: 419-407-5342
  • Fax: 419-407-5371
Mailing address:
  • Phone: 419-407-5342
  • Fax: 419-407-5371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.188363
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberQMHS
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: