Healthcare Provider Details

I. General information

NPI: 1013159391
Provider Name (Legal Business Name): MR. GERALD WENDELL BRANDON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2009
Last Update Date: 12/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 W SARATOGA ST
BALTIMORE MD
21223-1749
US

IV. Provider business mailing address

8214 ETHAN WAY
WINDSOR MILL MD
21244-2062
US

V. Phone/Fax

Practice location:
  • Phone: 410-735-5225
  • Fax:
Mailing address:
  • Phone: 410-383-8300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: