Provider Demographics
NPI:1487427225
Name:QUALLS, BROCKLIN (MED)
Entity type:Individual
Prefix:
First Name:BROCKLIN
Middle Name:
Last Name:QUALLS
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11870 GRAND PARK AVE APT 333
Mailing Address - Street 2:
Mailing Address - City:NORTH BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20852-8692
Mailing Address - Country:US
Mailing Address - Phone:202-560-0921
Mailing Address - Fax:
Practice Address - Street 1:11870 GRAND PARK AVE APT 333
Practice Address - Street 2:
Practice Address - City:NORTH BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20852-8692
Practice Address - Country:US
Practice Address - Phone:202-560-0921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-02
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator