Provider Demographics
NPI:1245314731
Name:BRADDOCK, MARLON ROBERT (MA)
Entity type:Individual
Prefix:MR
First Name:MARLON
Middle Name:ROBERT
Last Name:BRADDOCK
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42R SHEPARD ST
Mailing Address - Street 2:APARTMENT #2
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-3349
Mailing Address - Country:US
Mailing Address - Phone:617-769-7244
Mailing Address - Fax:
Practice Address - Street 1:12 HANCOCK CT
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-5210
Practice Address - Country:US
Practice Address - Phone:617-769-7244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health