Provider Demographics
NPI:1609965110
Name:BROWN, KEITH JOSEPH (PHD, PCC-S)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:JOSEPH
Last Name:BROWN
Suffix:
Gender:M
Credentials:PHD, PCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7680 POND BROOK LN
Mailing Address - Street 2:
Mailing Address - City:MACEDONIA
Mailing Address - State:OH
Mailing Address - Zip Code:44056-2358
Mailing Address - Country:US
Mailing Address - Phone:216-469-5629
Mailing Address - Fax:
Practice Address - Street 1:141 E AURORA RD
Practice Address - Street 2:SUITE 1
Practice Address - City:NORTHFIELD
Practice Address - State:OH
Practice Address - Zip Code:44067-2091
Practice Address - Country:US
Practice Address - Phone:330-467-1825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE-4349-SUP101Y00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH11471436OtherCAQH PROVIDER IDENTIFICATION NUMBER