Provider Demographics
NPI:1487088084
Name:BROWN, ANTONIO DREVEL
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:DREVEL
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 1:4840 SAN GABRIEL CT NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-2640
Mailing Address - Country:US
Mailing Address - Phone:503-931-2701
Mailing Address - Fax:
Practice Address - Street 1:4840 SAN GABRIEL CT NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-2640
Practice Address - Country:US
Practice Address - Phone:503-931-2701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-30
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor