Provider Demographics
NPI:1770177826
Name:BROWN, JELISA MARIE (SLP-A)
Entity type:Individual
Prefix:
First Name:JELISA
Middle Name:MARIE
Last Name:BROWN
Suffix:
Gender:F
Credentials:SLP-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7220 NW 114TH AVE # 20216
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-5562
Mailing Address - Country:US
Mailing Address - Phone:787-439-2552
Mailing Address - Fax:
Practice Address - Street 1:7220 NW 114TH AVE # 20216
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-5562
Practice Address - Country:US
Practice Address - Phone:787-439-2552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-01
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSI55062355S0801X
SC7523235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP7866Medicaid