Provider Demographics
NPI:1447789474
Name:BROWN, BRADLY (CMH)
Entity Type:Individual
Prefix:
First Name:BRADLY
Middle Name:
Last Name:BROWN
Suffix:
Gender:M
Credentials:CMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4944 S SHERWOOD FOREST BLVD APT 110
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-4611
Mailing Address - Country:US
Mailing Address - Phone:225-678-4725
Mailing Address - Fax:
Practice Address - Street 1:3084 WESTFORK DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-2254
Practice Address - Country:US
Practice Address - Phone:225-678-4725
Practice Address - Fax:225-678-4725
Is Sole Proprietor?:No
Enumeration Date:2017-06-04
Last Update Date:2017-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LABB210Medicaid