Provider Demographics
NPI:1255455267
Name:BROWN, WILLARD WISHARD (MA PSYCHOLOGY)
Entity type:Individual
Prefix:MR
First Name:WILLARD
Middle Name:WISHARD
Last Name:BROWN
Suffix:
Gender:M
Credentials:MA PSYCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 TRIPLE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:EFLAND
Mailing Address - State:NC
Mailing Address - Zip Code:27243-9573
Mailing Address - Country:US
Mailing Address - Phone:919-304-5670
Mailing Address - Fax:
Practice Address - Street 1:339 TRIPLE CREEK DR
Practice Address - Street 2:
Practice Address - City:EFLAND
Practice Address - State:NC
Practice Address - Zip Code:27243-9573
Practice Address - Country:US
Practice Address - Phone:919-304-5670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6111989Medicaid