Provider Demographics
NPI:1447608641
Name:BROWN, PEARL (APC)
Entity Type:Individual
Prefix:
First Name:PEARL
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:APC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 FANT DR
Mailing Address - Street 2:
Mailing Address - City:FT OGLETHORPE
Mailing Address - State:GA
Mailing Address - Zip Code:30742-3307
Mailing Address - Country:US
Mailing Address - Phone:706-806-1140
Mailing Address - Fax:
Practice Address - Street 1:1875 FANT DR
Practice Address - Street 2:
Practice Address - City:FORT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-3307
Practice Address - Country:US
Practice Address - Phone:706-806-1140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-27
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC005278101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA58-2108521Medicaid