=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962179762
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUSTIN MICHAEL BROWN LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2021
-----------------------------------------------------
Last Update Date | 08/27/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5700 OLD RICHMOND AVE STE A1
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23226-1828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-476-8543
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12406 BALTA RD
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23838-2957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-476-8543
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 0701010700
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------