Provider Demographics
NPI:1174785067
Name:BROWN, HOMER ROOSEVELT
Entity type:Individual
Prefix:MR
First Name:HOMER
Middle Name:ROOSEVELT
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 1:992 DEMARET DRIVE
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-2333
Mailing Address - Country:US
Mailing Address - Phone:321-632-3427
Mailing Address - Fax:
Practice Address - Street 1:992 DEMARET DRIVE
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2333
Practice Address - Country:US
Practice Address - Phone:321-698-8822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-01
Last Update Date:2013-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN1258341164W00000X
FLMH12133101YM0800X
FL1033055101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool