Provider Demographics
NPI:1548633183
Name:BROWN, SHANIEQUA (LADC)
Entity type:Individual
Prefix:
First Name:SHANIEQUA
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 BULL HILL LN
Mailing Address - Street 2:SUITE 321
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-3928
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:153 BULL HILL LN
Practice Address - Street 2:SUITE 321
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-3928
Practice Address - Country:US
Practice Address - Phone:999-999-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-04
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1170101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008062470OtherBROWN MEDICAID #
CT008001325Medicaid
CT008056033Medicaid
CT008062470OtherBROWN MEDICAID #
CT008022622Medicaid