Provider Demographics
NPI:1124296728
Name:BROWN, ERIC
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:BROWN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7369
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92375-0369
Mailing Address - Country:US
Mailing Address - Phone:909-792-0747
Mailing Address - Fax:909-792-2045
Practice Address - Street 1:309 E MOUNTAIN VIEW ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-2814
Practice Address - Country:US
Practice Address - Phone:760-256-0376
Practice Address - Fax:760-266-0377
Is Sole Proprietor?:No
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3005OtherSIMON STAFF NUMBER