Provider Demographics
NPI:1629108162
Name:BROWN, J MARTIN (PHD)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:MARTIN
Last Name:BROWN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 GASTON AVE
Mailing Address - Street 2:1155 WADLEY
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246
Mailing Address - Country:US
Mailing Address - Phone:214-824-2273
Mailing Address - Fax:214-826-9340
Practice Address - Street 1:3600 GASTON AVENUE
Practice Address - Street 2:1155 WADLEY
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246
Practice Address - Country:US
Practice Address - Phone:214-824-2273
Practice Address - Fax:214-826-9340
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0848101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0848OtherSTATE LICENSE
TX0848OtherSTATE LICENSE