Healthcare Provider Details

I. General information

NPI: 1679701593
Provider Name (Legal Business Name): LAVERNE RUSSELL BRAXTON LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 06/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2609 ALLENDALE RD
BALTIMORE MD
21216-2109
US

IV. Provider business mailing address

2609 ALLENDALE RD
BALTIMORE MD
21216-2109
US

V. Phone/Fax

Practice location:
  • Phone: 410-466-6978
  • Fax: 410-466-6978
Mailing address:
  • Phone: 410-466-6978
  • Fax: 410-466-6978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number04159
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: