Provider Demographics
NPI:1144233750
Name:BROWN, STELLA W (PHD)
Entity Type:Individual
Prefix:
First Name:STELLA
Middle Name:W
Last Name:BROWN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2614 SOUTHERLAND ST
Mailing Address - Street 2:SUITE ONE
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4858
Mailing Address - Country:US
Mailing Address - Phone:601-362-2624
Mailing Address - Fax:601-362-2622
Practice Address - Street 1:2614 SOUTHERLAND ST
Practice Address - Street 2:SUITE ONE
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4858
Practice Address - Country:US
Practice Address - Phone:601-362-2624
Practice Address - Fax:601-362-2622
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS35-571103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00117542Medicaid
MSS35878Medicare UPIN