Provider Demographics
NPI:1780206680
Name:BROWN, TAKEYLA MARIA
Entity Type:Individual
Prefix:
First Name:TAKEYLA
Middle Name:MARIA
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 1:1243 JOSEPHINE ST
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33815-4235
Mailing Address - Country:US
Mailing Address - Phone:407-860-2550
Mailing Address - Fax:
Practice Address - Street 1:1243 JOSEPHINE ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33815-4235
Practice Address - Country:US
Practice Address - Phone:407-860-2550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
385HR2055X
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child