Provider Demographics
NPI:1891834503
Name:BROWN, SUSAN E (PSYD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:BROWN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:BECKY
Other - Middle Name:
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1137
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32902-1137
Mailing Address - Country:US
Mailing Address - Phone:321-952-9696
Mailing Address - Fax:321-952-7937
Practice Address - Street 1:515 22ND AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WI
Practice Address - Zip Code:53566-1569
Practice Address - Country:US
Practice Address - Phone:608-324-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY11582103T00000X
MECP1205103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPY11582OtherMEDICAL LICENSE
ME432430599Medicaid