Provider Demographics
NPI:1205651882
Name:BROWN, MARTAVEOUS D
Entity type:Individual
Prefix:
First Name:MARTAVEOUS
Middle Name:D
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 1:435 GREENE 773 RD
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-9638
Mailing Address - Country:US
Mailing Address - Phone:870-205-3188
Mailing Address - Fax:870-292-3580
Practice Address - Street 1:435 GREENE 773 RD
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-9638
Practice Address - Country:US
Practice Address - Phone:870-205-3188
Practice Address - Fax:870-292-3580
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician