Healthcare Provider Details

I. General information

NPI: 1487570859
Provider Name (Legal Business Name): OMEGA BRODERICK PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 WADE AVE
CATONSVILLE MD
21228-4663
US

IV. Provider business mailing address

479 CEDAR LN
SEVERN MD
21144-1319
US

V. Phone/Fax

Practice location:
  • Phone: 410-402-7851
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number06478
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: