Provider Demographics
NPI:1407947096
Name:BROWN, CRETE
Entity Type:Individual
Prefix:MS
First Name:CRETE
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 NORTH 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204
Mailing Address - Country:US
Mailing Address - Phone:208-251-2400
Mailing Address - Fax:208-233-4224
Practice Address - Street 1:303 NORTH 12TH AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204
Practice Address - Country:US
Practice Address - Phone:208-251-2400
Practice Address - Fax:208-233-4224
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID5291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical