Provider Demographics
NPI:1295248821
Name:BROWN, MARY J
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 ALPHA ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-3508
Mailing Address - Country:US
Mailing Address - Phone:517-303-9577
Mailing Address - Fax:
Practice Address - Street 1:4221 S MLK BLVD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-5201
Practice Address - Country:US
Practice Address - Phone:517-303-9577
Practice Address - Fax:517-316-6114
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-06
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016356101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health