Provider Demographics
NPI:1336312107
Name:BROWN, MITCHELL RALPH (CDP)
Entity Type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:RALPH
Last Name:BROWN
Suffix:
Gender:M
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 BAY STREET
Mailing Address - Street 2:SUITE 24
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366
Mailing Address - Country:US
Mailing Address - Phone:360-602-0022
Mailing Address - Fax:360-335-6432
Practice Address - Street 1:1014 BAY STREET
Practice Address - Street 2:SUITE 24
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366
Practice Address - Country:US
Practice Address - Phone:360-452-4432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-11
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00059266101YA0400X
WACP60099064101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)