Provider Demographics
NPI:1962476010
Name:BROWN, FRED HARRY JR (PH D)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:HARRY
Last Name:BROWN
Suffix:JR
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:268 WAXHAW ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-8628
Mailing Address - Country:US
Mailing Address - Phone:910-286-0664
Mailing Address - Fax:
Practice Address - Street 1:268 WAXHAW ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-8628
Practice Address - Country:US
Practice Address - Phone:910-286-0664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1629103TC0700X
103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist