Provider Demographics
NPI:1508076118
Name:BROWN, ELAINE GORDON (BSW)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:GORDON
Last Name:BROWN
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1485 SOUTH M-139
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022
Mailing Address - Country:US
Mailing Address - Phone:269-925-2391
Mailing Address - Fax:269-927-8650
Practice Address - Street 1:1485 SOUTH M-139
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022
Practice Address - Country:US
Practice Address - Phone:269-925-2391
Practice Address - Fax:269-927-8650
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802060964104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker