Healthcare Provider Details

I. General information

NPI: 1144755802
Provider Name (Legal Business Name): MRS. TRACI BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2017
Last Update Date: 11/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5505 GRISSOM RD STE 103
SAN ANTONIO TX
78238-3024
US

IV. Provider business mailing address

70 S RIVER ST
AURORA IL
60506-5185
US

V. Phone/Fax

Practice location:
  • Phone: 210-680-4747
  • Fax: 210-680-4775
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number203706
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: