Provider Demographics
NPI:1992570220
Name:BROWN, KENNETH II
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:BROWN
Suffix:II
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 1:1658 AUTUMN SAGE DR
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-7278
Mailing Address - Country:US
Mailing Address - Phone:404-707-1953
Mailing Address - Fax:
Practice Address - Street 1:2576 LAWRENCEVILLE SUWANEE RD
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-7290
Practice Address - Country:US
Practice Address - Phone:678-731-7727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-16
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health