Basic Information
| Provider Information | |||||||||
| NPI: | 1518553965 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | KHADIJAH | ||||||||
| MiddleName: | REGINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1567 HARVARD AVE APT 1 | ||||||||
| Address2: | |||||||||
| City: | COLLEGE PARK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303372960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4703992064 | ||||||||
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| Practice Location | |||||||||
| Address1: | 175 GWINNETT DR | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300468444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782092394 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2020 | ||||||||
| LastUpdateDate: | 12/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | MSW009592 | GA | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.