Provider Demographics
NPI:1952761355
Name:BROWN, BETTY
Entity type:Individual
Prefix:
First Name:BETTY
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 1:300 JOSEPH AVE
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TX
Mailing Address - Zip Code:75654-4334
Mailing Address - Country:US
Mailing Address - Phone:903-658-4855
Mailing Address - Fax:903-392-8915
Practice Address - Street 1:300 JOSEPH AVE
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TX
Practice Address - Zip Code:75654-4334
Practice Address - Country:US
Practice Address - Phone:903-658-4855
Practice Address - Fax:903-392-8915
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-26
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX126482171W00000X, 311ZA0620X
TX311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX505489714Medicaid