Provider Demographics
NPI:1275932014
Name:BROWN, THOMAS E
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:E
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 1:580 ELLIS RD S STE 118
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32254-3567
Mailing Address - Country:US
Mailing Address - Phone:904-745-0067
Mailing Address - Fax:
Practice Address - Street 1:811 MADISON ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-4543
Practice Address - Country:US
Practice Address - Phone:425-212-4200
Practice Address - Fax:425-212-4201
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-18
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACAAR.CG.60500645101Y00000X, 3104A0625X, 320600000X
WA101YP2500X
FL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities