Provider Demographics
NPI:1447315049
Name:BROWN, VIKKI L (EDD)
Entity type:Individual
Prefix:DR
First Name:VIKKI
Middle Name:L
Last Name:BROWN
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:872 MASSACHUSETTS AVE
Mailing Address - Street 2:STE 2-1
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-3072
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:872 MASSACHUSETTS AVE
Practice Address - Street 2:STE 2-1
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-3072
Practice Address - Country:US
Practice Address - Phone:617-661-1688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6495103T00000X, 103TA0700X, 103TB0200X, 103TC0700X, 103TH0004X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW05194Medicare ID - Type Unspecified