Healthcare Provider Details

I. General information

NPI: 1134067358
Provider Name (Legal Business Name): HEATHER BROCKBRADER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEATHER BUTLER

II. Dates (important events)

Enumeration Date: 03/23/2026
Last Update Date: 03/23/2026
Certification Date: 03/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 W LOMBARD ST
BALTIMORE MD
21201-1512
US

IV. Provider business mailing address

7808 MAPLE RUN CT
GLEN BURNIE MD
21060-8667
US

V. Phone/Fax

Practice location:
  • Phone: 410-706-0501
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: