Provider Demographics
NPI:1992524458
Name:BROWN, KIWAN A I (MA, BCABA)
Entity type:Individual
Prefix:
First Name:KIWAN
Middle Name:A
Last Name:BROWN
Suffix:I
Gender:M
Credentials:MA, BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 FORREST AVE
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-7991
Mailing Address - Country:US
Mailing Address - Phone:917-683-0748
Mailing Address - Fax:
Practice Address - Street 1:12493 BRANTLEY COMMONS CT
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907
Practice Address - Country:US
Practice Address - Phone:239-268-8707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-24-15498103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty