Basic Information
| Provider Information | |||||||||
| NPI: | 1013350867 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | NICHOLAS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPCC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BROWN | ||||||||
| OtherFirstName: | JORDAN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPCC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 635283 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452635283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8597570717 | ||||||||
| FaxNumber: | 8593312425 | ||||||||
| Practice Location | |||||||||
| Address1: | 351 CENTRE VIEW BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | CRESTVIEW HILLS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8597570717 | ||||||||
| FaxNumber: | 8593312425 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2013 | ||||||||
| LastUpdateDate: | 04/12/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LPCPCC00218319 | KY | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 1591 | KY | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | 164140 | KY | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | LPCPCC00218319 | KY | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 7100333760 | 05 | KY | MEDICAID | 611300608 | 01 | KY | TAX IDENTIFICATION NUMBER | OTHER | 610661458 | 01 | KY | TAX ID | OTHER | 0155170 | 05 | OH | MEDICAID |