Provider Demographics
NPI:1619185709
Name:BROWN, BENJAMIN RICHARD (MA CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:RICHARD
Last Name:BROWN
Suffix:
Gender:M
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1057 LUNDY CT
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-6115
Mailing Address - Country:US
Mailing Address - Phone:407-304-6901
Mailing Address - Fax:
Practice Address - Street 1:1408 N WEST SHORE BLVD
Practice Address - Street 2:300
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-4525
Practice Address - Country:US
Practice Address - Phone:407-304-6901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 8330235Z00000X
HISP 942235Z00000X
MA7069235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist