Provider Demographics
NPI:1225478548
Name:BROWN, DEREK CHARLES
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:CHARLES
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 1:2825 PHEASANT RUN
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-6607
Mailing Address - Country:US
Mailing Address - Phone:405-395-8610
Mailing Address - Fax:
Practice Address - Street 1:3621 N KELLEY AVE
Practice Address - Street 2:STE. 100
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73111-4520
Practice Address - Country:US
Practice Address - Phone:405-524-5525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-01
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1578690137101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)