Provider Demographics
NPI:1154894699
Name:BUSTER-BROWN, ORPHEUS GABRIEL
Entity type:Individual
Prefix:MR
First Name:ORPHEUS
Middle Name:GABRIEL
Last Name:BUSTER-BROWN
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:ORPHEUS
Other - Middle Name:GABRIEL
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:135 PAUL DRIVE
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903
Mailing Address - Country:US
Mailing Address - Phone:415-492-4444
Mailing Address - Fax:415-492-8844
Practice Address - Street 1:135 PAUL DRIVE
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903
Practice Address - Country:US
Practice Address - Phone:415-492-4444
Practice Address - Fax:415-492-8844
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)