Provider Demographics
NPI:1629568142
Name:BROWN, CHARLES
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:BROWN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8820 SOUTHERN BREEZE DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32836-5011
Mailing Address - Country:US
Mailing Address - Phone:407-810-7143
Mailing Address - Fax:
Practice Address - Street 1:2145 METROCENTER BLVD STE 350
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-7642
Practice Address - Country:US
Practice Address - Phone:407-218-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL324500000X, 101YP1600X
FL120417101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL120417OtherINTERNATIONAL CERTIFICATION AND RECIPROCITY CONTINUUM
FL800OtherCERTIFICATION BOARD OF ADDICTIONS PROFESSIONALS