Provider Demographics
NPI:1336122530
Name:BROWN, ROBERT WAYNE JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WAYNE
Last Name:BROWN
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:R
Other - Middle Name:WAYNE
Other - Last Name:BROWN
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:18800 DELAWARE STREET
Mailing Address - Street 2:#700
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-6018
Mailing Address - Country:US
Mailing Address - Phone:714-847-4788
Mailing Address - Fax:714-841-7818
Practice Address - Street 1:18800 DELAWARE STREET
Practice Address - Street 2:#700
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-6018
Practice Address - Country:US
Practice Address - Phone:714-847-4788
Practice Address - Fax:714-841-7818
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACP4060103TC0700X
CAPSY4060103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP4060OtherSTATE LICENCE
CACP4060OtherSTATE LICENCE
CACP4060Medicare UPIN
R91229Medicare PIN