Healthcare Provider Details

I. General information

NPI: 1295283836
Provider Name (Legal Business Name): CODY BROWN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2016
Last Update Date: 09/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 N SARA RD
TUTTLE OK
73089-8509
US

IV. Provider business mailing address

925 N. SARA ROAD
TUTTLE OK
73089
US

V. Phone/Fax

Practice location:
  • Phone: 619-608-7648
  • Fax:
Mailing address:
  • Phone: 619-608-7648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: