Provider Demographics
NPI:1891075826
Name:BROWN, DEREK MONTEL II
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:MONTEL
Last Name:BROWN
Suffix:II
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 1:1812 WENGERT AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-1933
Mailing Address - Country:US
Mailing Address - Phone:702-338-3082
Mailing Address - Fax:
Practice Address - Street 1:5420 W SAHARA AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-0394
Practice Address - Country:US
Practice Address - Phone:702-436-4247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-22
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation