Provider Demographics
NPI:1356900898
Name:BROWN, KENDAL SIMEON (LCAS)
Entity type:Individual
Prefix:
First Name:KENDAL
Middle Name:SIMEON
Last Name:BROWN
Suffix:
Gender:M
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4830 TUTELO TRL
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-9419
Mailing Address - Country:US
Mailing Address - Phone:540-629-3308
Mailing Address - Fax:
Practice Address - Street 1:4830 TUTELO TRL
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-9419
Practice Address - Country:US
Practice Address - Phone:540-629-3308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-09
Last Update Date:2019-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-25015101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCLCAC-25015Medicaid