Provider Demographics
NPI:1104039346
Name:BROWN, RICHARD WILLIS (LCSW)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:WILLIS
Last Name:BROWN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 E ELLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-9353
Mailing Address - Country:US
Mailing Address - Phone:503-623-5588
Mailing Address - Fax:503-623-4729
Practice Address - Street 1:2200 E ELLENDALE AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-9353
Practice Address - Country:US
Practice Address - Phone:503-623-5588
Practice Address - Fax:503-623-4729
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR806101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health