Provider Demographics
NPI:1245742477
Name:BYRUM, CASSONDRA (BS)
Entity Type:Individual
Prefix:
First Name:CASSONDRA
Middle Name:
Last Name:BYRUM
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 REVERE DR STE 120
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-8005
Mailing Address - Country:US
Mailing Address - Phone:847-807-3917
Mailing Address - Fax:847-348-3706
Practice Address - Street 1:3333 UNIVERSITY AVE SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-3325
Practice Address - Country:US
Practice Address - Phone:612-767-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-27
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CO1-20-43633103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician