Provider Demographics
NPI:1851755821
Name:BROWN, MONIQUE
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
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 1:2483 LAKE DR
Mailing Address - Street 2:# 132
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20601-7223
Mailing Address - Country:US
Mailing Address - Phone:240-640-0402
Mailing Address - Fax:
Practice Address - Street 1:2483 LAKE DR
Practice Address - Street 2:# 132
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-7223
Practice Address - Country:US
Practice Address - Phone:240-640-0402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-06
Last Update Date:2019-12-18
Deactivation Date:2019-11-14
Deactivation Code:
Reactivation Date:2019-12-18
Provider Licenses
StateLicense IDTaxonomies
MDLGP4059101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health