Provider Demographics
NPI:1972211225
Name:BROWN, MARY LOUISE (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:BROWN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:538 MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-3782
Mailing Address - Country:US
Mailing Address - Phone:208-859-9585
Mailing Address - Fax:
Practice Address - Street 1:3770 E BLACK CANYON HWY
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-9503
Practice Address - Country:US
Practice Address - Phone:208-365-3437
Practice Address - Fax:208-365-7235
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-334321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical