Provider Demographics
NPI:1164661625
Name:WASHINGTON, BRIAN KEITH SR (LADC)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:KEITH
Last Name:WASHINGTON
Suffix:SR
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11 CAPE DR
Mailing Address - Street 2:BUILDING A SUITE 1
Mailing Address - City:MASHPEE
Mailing Address - State:MA
Mailing Address - Zip Code:02649-3046
Mailing Address - Country:US
Mailing Address - Phone:508-539-9245
Mailing Address - Fax:508-375-0083
Practice Address - Street 1:11 CAPE DR
Practice Address - Street 2:BUILDING A SUITE 1
Practice Address - City:MASHPEE
Practice Address - State:MA
Practice Address - Zip Code:02649-3046
Practice Address - Country:US
Practice Address - Phone:508-539-9245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-06
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1787101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)