Provider Demographics
NPI:1164500641
Name:BROWN, KIMBERLY (MA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5304 N BAYON DR
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-5751
Mailing Address - Country:US
Mailing Address - Phone:765-273-7313
Mailing Address - Fax:765-273-7313
Practice Address - Street 1:4607 N WHEELING AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-1220
Practice Address - Country:US
Practice Address - Phone:765-288-1110
Practice Address - Fax:765-288-4044
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001560A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200447850Medicaid
IN200447850Medicaid