Healthcare Provider Details

I. General information

NPI: 1558689323
Provider Name (Legal Business Name): DARRYL EDWARD BRAXTON LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: DARRYL EDWARD BRAXTON LCPC-702

II. Dates (important events)

Enumeration Date: 05/04/2010
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3808 EASTERN AVE
BALTIMORE MD
21224-4221
US

IV. Provider business mailing address

919 CALWELL RD
BALTIMORE MD
21229-5006
US

V. Phone/Fax

Practice location:
  • Phone: 443-882-1943
  • Fax:
Mailing address:
  • Phone: 443-882-1943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC7034
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLCA1542
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: