Provider Demographics
NPI:1083294896
Name:BROWN, MICKENZIE (LCDC III)
Entity type:Individual
Prefix:
First Name:MICKENZIE
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:LCDC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3231 CENTRAL PARK W STE 106
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43617-3009
Mailing Address - Country:US
Mailing Address - Phone:888-442-2323
Mailing Address - Fax:
Practice Address - Street 1:3231 CENTRAL PARK W STE 106
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43617-3009
Practice Address - Country:US
Practice Address - Phone:888-442-2323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-14
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X, 101YM0800X
OHLCDCIII.162645101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health