Provider Demographics
NPI:1083713861
Name:BRUM, LILLIE (MFT 8571)
Entity Type:Individual
Prefix:
First Name:LILLIE
Middle Name:
Last Name:BRUM
Suffix:
Gender:F
Credentials:MFT 8571
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 SAN PABLO AVE
Mailing Address - Street 2:#9
Mailing Address - City:ALBANY
Mailing Address - State:CA
Mailing Address - Zip Code:94706
Mailing Address - Country:US
Mailing Address - Phone:510-524-6185
Mailing Address - Fax:510-526-8948
Practice Address - Street 1:1035 SAN PABLO AVE
Practice Address - Street 2:#9
Practice Address - City:ALBANY
Practice Address - State:CA
Practice Address - Zip Code:94706
Practice Address - Country:US
Practice Address - Phone:510-524-6185
Practice Address - Fax:510-526-8948
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT8571106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist