Basic Information
| Provider Information | |||||||||
| NPI: | 1376696625 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | DELORES | ||||||||
| MiddleName: | |||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 918 | ||||||||
| Address2: | 1035 CHERAW ST. | ||||||||
| City: | BENNETTSVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435444098 | ||||||||
| FaxNumber: | 8642411124 | ||||||||
| Practice Location | |||||||||
| Address1: | 1324 COMMERCE DR. | ||||||||
| Address2: | |||||||||
| City: | DILLON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437743351 | ||||||||
| FaxNumber: | 8642411124 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2007 | ||||||||
| LastUpdateDate: | 04/10/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 405127 | 05 | SC | MEDICAID |