Provider Demographics
NPI:1881988194
Name:BROWN, LARITA FAY
Entity type:Individual
Prefix:
First Name:LARITA
Middle Name:FAY
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 1:636 SW 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-4442
Mailing Address - Country:US
Mailing Address - Phone:541-760-0950
Mailing Address - Fax:
Practice Address - Street 1:90850 TERRITORIAL HWY
Practice Address - Street 2:
Practice Address - City:JUNCTION CITY
Practice Address - State:OR
Practice Address - Zip Code:97448-8513
Practice Address - Country:US
Practice Address - Phone:541-760-0950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-03
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health