Provider Demographics
NPI:1679701593
Name:BRAXTON, LAVERNE RUSSELL (LCSW-C)
Entity type:Individual
Prefix:MS
First Name:LAVERNE
Middle Name:RUSSELL
Last Name:BRAXTON
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2609 ALLENDALE RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21216-2109
Mailing Address - Country:US
Mailing Address - Phone:410-466-6978
Mailing Address - Fax:410-466-6978
Practice Address - Street 1:2609 ALLENDALE RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216-2109
Practice Address - Country:US
Practice Address - Phone:410-466-6978
Practice Address - Fax:410-466-6978
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-30
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD041591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical