MEDICARE: MR. CHARLES BROWN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility		FL
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	120417	FL
3	101YP1600X	Pastoral Counselor		FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	120417	OTHER	FL	INTERNATIONAL CERTIFICATION AND RECIPROCITY CONTINUUM
2	800	OTHER	FL	CERTIFICATION BOARD OF ADDICTIONS PROFESSIONALS

General Provider Information

NPI Number	:	1629568142
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES BROWN

Provider Business Mailing Address
First Line	:	8820 SOUTHERN BREEZE DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32836-5011
Country	:	US
Telephone Number	:	407-810-7143
Fax Number	:

Provider Business Practice Location Address
First Line	:	2145 METROCENTER BLVD STE 350
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32835-7642
Country	:	US
Telephone Number	:	407-218-4800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/10/2018
Last Update Date	:	05/10/2018

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Directions to “ MR. CHARLES BROWN ” Practice Location

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