Provider Demographics
NPI:1528573250
Name:BROWN, KEVIN LEE (LMFT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:LEE
Last Name:BROWN
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 SHALFORD WAY
Mailing Address - Street 2:
Mailing Address - City:GALT
Mailing Address - State:CA
Mailing Address - Zip Code:95632-3771
Mailing Address - Country:US
Mailing Address - Phone:208-712-0466
Mailing Address - Fax:
Practice Address - Street 1:446 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:GALT
Practice Address - State:CA
Practice Address - Zip Code:95632-2012
Practice Address - Country:US
Practice Address - Phone:209-712-0466
Practice Address - Fax:209-712-0466
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40221101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA40221OtherLICENSED MARRIAGE AND FAMILY THERAPIST