Provider Demographics
NPI:1265081673
Name:BROWN, JUSTIN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
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 1:510 MAIN ST. GORHAM, ME 04038
Mailing Address - Street 2:
Mailing Address - City:GORHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04038
Mailing Address - Country:US
Mailing Address - Phone:207-200-8661
Mailing Address - Fax:207-222-0066
Practice Address - Street 1:510 MAIN ST. GORHAM, ME 04038
Practice Address - Street 2:
Practice Address - City:GORHAM
Practice Address - State:ME
Practice Address - Zip Code:04038
Practice Address - Country:US
Practice Address - Phone:207-200-8661
Practice Address - Fax:207-222-0066
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC17463101Y00000X
LC192781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1164484093OtherDAY ONE NPI