1558689323 NPI number — MR. DARRYL EDWARD BRAXTON LCPC

Table of content: MR. DARRYL EDWARD BRAXTON LCPC (NPI 1558689323)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558689323 NPI number — MR. DARRYL EDWARD BRAXTON LCPC

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
BRAXTON

Provider First Name:
DARRYL

Provider Middle Name:
EDWARD

Provider Name Prefix Text:
MR.

Provider Name Suffix Text:

Provider Credential Text:
LCPC

Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:
BRAXTON

Provider Other First Name:
DARRYL

Provider Other Middle Name:
EDWARD

Provider Other Name Prefix Text:
MR.

Provider Other Name Suffix Text:

Provider Other Credential Text:
LCPC-702

Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1558689323

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
05/11/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
919 CALWELL RD

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:
BALTIMORE

Provider Business Mailing Address State Name:
MD

Provider Business Mailing Address Postal Code:
21229-5006

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
443-882-1943

Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3808 EASTERN AVE

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:
BALTIMORE

Provider Business Practice Location Address State Name:
MD

Provider Business Practice Location Address Postal Code:
21224-4221

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
443-882-1943

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:
05/04/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

Provider Taxonomy Codes

Taxonomy code: 101YP2500X , with the licence number: LCA1542 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Taxonomy code: 101YM0800X , with the licence number: LC7034 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .