Healthcare Provider Details

I. General information

NPI: 1457193278
Provider Name (Legal Business Name): MALCOLM L BROADNAX
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2024
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4412 COLE FARM RD
NOTTINGHAM MD
21236-2961
US

IV. Provider business mailing address

2710 PELHAM AVE
BALTIMORE MD
21213-1119
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCA3486
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGP14898
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: