Basic Information
| Provider Information | |||||||||
| NPI: | 1114292273 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | RAYMOND | ||||||||
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| Credential: | LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4806 DODGE ST APT 5 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681323136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4029321558 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8502 MORMON BRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681521929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4029918558 | ||||||||
| FaxNumber: | 4024557050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2012 | ||||||||
| LastUpdateDate: | 03/21/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 913 | NE | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 913 | 01 | NE | NDHHS | OTHER |