Provider Demographics
NPI:1376925768
Name:BROWN, DERON
Entity Type:Individual
Prefix:
First Name:DERON
Middle Name:
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 1:1322 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANTLERS
Mailing Address - State:OK
Mailing Address - Zip Code:74523-2016
Mailing Address - Country:US
Mailing Address - Phone:580-298-5062
Mailing Address - Fax:
Practice Address - Street 1:1322 W 9TH ST
Practice Address - Street 2:
Practice Address - City:ANTLERS
Practice Address - State:OK
Practice Address - Zip Code:74523-9308
Practice Address - Country:US
Practice Address - Phone:580-579-3450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-23
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200626640Medicaid