Healthcare Provider Details

I. General information

NPI: 1225856743
Provider Name (Legal Business Name): BIANCA M BRADDY ADT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2024
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 N POINT BLVD STE 128
BALTIMORE MD
21224-3417
US

IV. Provider business mailing address

809 OLYMPIC SQ UNIT 132
ABERDEEN MD
21001-3973
US

V. Phone/Fax

Practice location:
  • Phone: 443-231-3040
  • Fax:
Mailing address:
  • Phone: 410-877-5489
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberADT2230
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: