Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | A-2256-0001-A | IL |
NPI | 1629553748 |
---|---|
Provider Name | Malcolm Brown |
First Address | Chicago, IL 60644-3413 |
Second Address | Chicago, IL 60644-3413 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/09/2018 |
Last Update Date | 22/10/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
008144 | (05) | IL |
1629553748 | (05) | IL |
A-2256-0001-A | (05) | IL |