Provider Demographics
NPI:1922100585
Name:BROWN, GLENDA G (MSW LCSW)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:G
Last Name:BROWN
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 538622
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-8622
Mailing Address - Country:US
Mailing Address - Phone:910-794-4521
Mailing Address - Fax:
Practice Address - Street 1:3205 RANDALL PKWY STE 105
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-2565
Practice Address - Country:US
Practice Address - Phone:910-742-9243
Practice Address - Fax:888-746-1787
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0048811041C0700X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC141UWOtherBCBS
NC6003787Medicaid
NC6003787Medicaid