Provider Demographics
NPI:1639571524
Name:BROWN, MARY LARUE
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:LARUE
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 W GRAND VALLEY AVE
Mailing Address - Street 2:
Mailing Address - City:ORWELL
Mailing Address - State:OH
Mailing Address - Zip Code:44076-9437
Mailing Address - Country:US
Mailing Address - Phone:440-437-6260
Mailing Address - Fax:440-437-2050
Practice Address - Street 1:111 W GRAND VALLEY AVE
Practice Address - Street 2:
Practice Address - City:ORWELL
Practice Address - State:OH
Practice Address - Zip Code:44076-9437
Practice Address - Country:US
Practice Address - Phone:440-437-6260
Practice Address - Fax:440-437-2050
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-23
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool