Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | CII2134 | IN |
NPI | 1003387127 |
---|---|
Provider Name | Jay Brown |
First Address | North Vernon, IN 47265-2454 |
Second Address | North Vernon, IN 47265-2454 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/12/2018 |
Last Update Date | 16/12/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
CII2134 | (05) | IN |