Provider Demographics
NPI:1023236114
Name:BROADBENT, JANAN (PHD)
Entity type:Individual
Prefix:DR
First Name:JANAN
Middle Name:
Last Name:BROADBENT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 HAMILL RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21210-1806
Mailing Address - Country:US
Mailing Address - Phone:410-825-5577
Mailing Address - Fax:410-468-2555
Practice Address - Street 1:2 HAMILL RD
Practice Address - Street 2:SUITE 120
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21210-1837
Practice Address - Country:US
Practice Address - Phone:410-825-5577
Practice Address - Fax:410-468-2555
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1275103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG078JOtherCAREFIRSTBLUECROSSBLUESHI
MDG078Medicare ID - Type Unspecified