Provider Demographics
NPI:1457193278
Name:BROADNAX, MALCOLM L
Entity type:Individual
Prefix:
First Name:MALCOLM
Middle Name:L
Last Name:BROADNAX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2710 PELHAM AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21213-1119
Mailing Address - Country:US
Mailing Address - Phone:443-528-0822
Mailing Address - Fax:
Practice Address - Street 1:4412 COLE FARM RD
Practice Address - Street 2:
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-2961
Practice Address - Country:US
Practice Address - Phone:443-528-0822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-11
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP14898101YM0800X
MDLCA3486101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health