Provider Demographics
NPI:1457625618
Name:BROWN, ILEARA
Entity type:Individual
Prefix:
First Name:ILEARA
Middle Name:
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 1:421 MANSFIELD CT SW APT B307
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98367-9813
Mailing Address - Country:US
Mailing Address - Phone:949-742-0718
Mailing Address - Fax:
Practice Address - Street 1:6625 WAGNER WAY STE 356
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-8392
Practice Address - Country:US
Practice Address - Phone:949-742-0718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-05
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF61117086106H00000X
CALMFT100416106H00000X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program