Provider Demographics
NPI:1114292273
Name:BROWN, ANTHONY RAYMOND (LADC)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:RAYMOND
Last Name:BROWN
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4806 DODGE ST APT 5
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68132-3136
Mailing Address - Country:US
Mailing Address - Phone:402-932-1558
Mailing Address - Fax:
Practice Address - Street 1:8502 MORMON BRIDGE RD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68152-1929
Practice Address - Country:US
Practice Address - Phone:402-991-8558
Practice Address - Fax:402-455-7050
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-21
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE913101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE913OtherNDHHS