Provider Demographics
NPI:1275733214
Name:BROWN, BECKY SUE (CAS 1997)
Entity Type:Individual
Prefix:MS
First Name:BECKY
Middle Name:SUE
Last Name:BROWN
Suffix:
Gender:F
Credentials:CAS 1997
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:559 MENDOCINO CT
Mailing Address - Street 2:
Mailing Address - City:ATWATER
Mailing Address - State:CA
Mailing Address - Zip Code:95301-4230
Mailing Address - Country:US
Mailing Address - Phone:209-357-5200
Mailing Address - Fax:209-357-5279
Practice Address - Street 1:559 MENDOCINO CT
Practice Address - Street 2:
Practice Address - City:ATWATER
Practice Address - State:CA
Practice Address - Zip Code:95301-4230
Practice Address - Country:US
Practice Address - Phone:209-357-5200
Practice Address - Fax:209-357-5279
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACAS 02979598324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility