Basic Information
| Provider Information | |||||||||
| NPI: | 1770927154 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | PRINCESS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1225 S OWASSO AVE APT B | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741205013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188129722 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11428 E 20TH ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741286451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188787877 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2013 | ||||||||
| LastUpdateDate: | 04/29/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 000000000 | 05 | OK | MEDICAID |