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NPI Code Detail

MEDICARE: MR. MARLON ROBERT BRADDOCK M.A.

MEDICARE: MR. MARLON ROBERT BRADDOCK M.A.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YM0800XMental Health Counselor

General Provider Information

NPI Number : 1245314731
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. MARLON ROBERT BRADDOCK M.A.
Provider Business Mailing Address
First Line : 42R SHEPARD ST
Second Line : APARTMENT #2
City : BRIGHTON
State : MA
Zip : 02135-3349
Country : US
Telephone Number : 617-769-7244
Fax Number :
Provider Business Practice Location Address
First Line : 12 HANCOCK CT
Second Line :
City : QUINCY
State : MA
Zip : 02169-5210
Country : US
Telephone Number : 617-769-7244
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/24/2006
Last Update Date : 07/08/2007

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