Healthcare Provider Details

I. General information

NPI: 1437992815
Provider Name (Legal Business Name): MR. BRANDON DICKENS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2024
Last Update Date: 06/14/2024
Certification Date: 06/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6405 LAURELTON AVE
BALTIMORE MD
21214-1134
US

IV. Provider business mailing address

1724 WYCLIFFE AVE
PARKVILLE MD
21234-6824
US

V. Phone/Fax

Practice location:
  • Phone: 410-622-4592
  • Fax:
Mailing address:
  • Phone: 410-622-4592
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: