Provider Demographics
NPI:1649637364
Name:BROWN, BRANDI (BCBA)
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7719 SARATOGA RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22153-2957
Mailing Address - Country:US
Mailing Address - Phone:708-625-6134
Mailing Address - Fax:
Practice Address - Street 1:2285 S LEXINGTON DR
Practice Address - Street 2:
Practice Address - City:MT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-5899
Practice Address - Country:US
Practice Address - Phone:708-725-6134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-26
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133000842103K00000X
IL11520828103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL11520828Medicaid