Provider Demographics
NPI:1114548047
Name:LABASS, BRAD FITZGERALD (LMFT)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:FITZGERALD
Last Name:LABASS
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 EVERGREEN LN
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-5415
Mailing Address - Country:US
Mailing Address - Phone:707-322-9994
Mailing Address - Fax:
Practice Address - Street 1:2255 CHALLENGER WAY STE 107
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-5423
Practice Address - Country:US
Practice Address - Phone:707-565-4797
Practice Address - Fax:707-565-4881
Is Sole Proprietor?:No
Enumeration Date:2020-05-01
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53462101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health