Provider Demographics
NPI:1215032727
Name:BROWN, LAWRENCE GLEN (MFT)
Entity Type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:GLEN
Last Name:BROWN
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 755
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94953-0755
Mailing Address - Country:US
Mailing Address - Phone:707-765-4868
Mailing Address - Fax:
Practice Address - Street 1:222 WELLER
Practice Address - Street 2:#204
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952
Practice Address - Country:US
Practice Address - Phone:707-765-4868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT 35511106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist