Basic Information
Provider Information | |||||||||
NPI: | 1467010413 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BROWN | ||||||||
FirstName: | BLANCHE | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS, LMFT-IT, LPC-IT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1337 S CESAR E CHAVEZ DR | ||||||||
Address2: |   | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 532042712 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: | 4146720191 | ||||||||
Practice Location | |||||||||
Address1: | 2906 S 20TH ST | ||||||||
Address2: |   | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 532153732 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4146721353 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/04/2019 | ||||||||
LastUpdateDate: | 04/06/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/06/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 4390226 | WI | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X |   |   | N |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   | 221700000X |   |   | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Art Therapist |   | 101YM0800X | 8256-125 | WI | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.