Provider Demographics
NPI:1639338718
Name:BROWN, RUSSELL ALLEN
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:ALLEN
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 1:5208 CLASSEN CIR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118-4429
Mailing Address - Country:US
Mailing Address - Phone:405-810-1766
Mailing Address - Fax:
Practice Address - Street 1:5208 CLASSEN CIR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-4429
Practice Address - Country:US
Practice Address - Phone:405-810-1766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-04
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK218101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)