Provider Demographics
NPI:1922694009
Name:BROWN, NICHOLAS EUGENE
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:EUGENE
Last Name:BROWN
Suffix:
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 1:123 GAMBLE AVE
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-5327
Mailing Address - Country:US
Mailing Address - Phone:304-242-2189
Mailing Address - Fax:
Practice Address - Street 1:123 GAMBLE AVE
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-5327
Practice Address - Country:US
Practice Address - Phone:304-242-2189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV00601669678Medicaid
WVH0503830101Medicaid