Basic Information
| Provider Information | |||||||||
| NPI: | 1528208725 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CCDS, CADCII | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2099 | ||||||||
| Address2: | |||||||||
| City: | KINGS BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961432099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305465641 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8491 NORTH LAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | KINGS BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 96143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305465641 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2009 | ||||||||
| LastUpdateDate: | 09/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | B0501021444 | CA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | A043760217 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | B0501021444 | 01 | CA | PROGRAM MANAGER | OTHER | 02148 | 01 | NV | NEVADA BOARD OF EXAMINERS | OTHER |