=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508665993
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOUGLAS EDWIN BROWN III
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2025
-----------------------------------------------------
Last Update Date | 03/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2219 SW 74TH ST STE 109-115
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73159-3931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-355-3239
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1900 NW 174TH ST
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73012-7067
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-508-0234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------