Healthcare Provider Details

I. General information

NPI: 1407740582
Provider Name (Legal Business Name): AWAKE & ROOTED WELLNESS & RECOVERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2025
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4412 COLE FARM RD
NOTTINGHAM MD
21236-2961
US

IV. Provider business mailing address

4412 COLE FARM RD
NOTTINGHAM MD
21236-2961
US

V. Phone/Fax

Practice location:
  • Phone: 443-528-0822
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MALCOLM LEE BROADNAX
Title or Position: OWNER
Credential: LCADC,LGPC
Phone: 443-528-0822