Provider Demographics
NPI:1225405483
Name:BROWN, COREY
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:BROWN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23375 STATE ROUTE 141
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:OH
Mailing Address - Zip Code:45688-9378
Mailing Address - Country:US
Mailing Address - Phone:740-464-9715
Mailing Address - Fax:
Practice Address - Street 1:23375 STATE ROUTE 141
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:OH
Practice Address - Zip Code:45688-9378
Practice Address - Country:US
Practice Address - Phone:740-464-9715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002138225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant