Healthcare Provider Details

I. General information

NPI: 1407779747
Provider Name (Legal Business Name): NICOLE BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NIKKI BROWN

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2406 MADISON DR
NORTH MYRTLE BEACH SC
29582-4334
US

IV. Provider business mailing address

2406 MADISON DR
NORTH MYRTLE BEACH SC
29582-4334
US

V. Phone/Fax

Practice location:
  • Phone: 843-663-0748
  • Fax:
Mailing address:
  • Phone: 843-663-0748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11087
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: