Provider Demographics
NPI:1275148694
Name:THAYER, BRAD WILLIAM (LPC, NCC, CCTP)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:WILLIAM
Last Name:THAYER
Suffix:
Gender:M
Credentials:LPC, NCC, CCTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 E FRY BLVD
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2712
Mailing Address - Country:US
Mailing Address - Phone:520-477-1863
Mailing Address - Fax:
Practice Address - Street 1:287 LORTON AVE
Practice Address - Street 2:
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-4203
Practice Address - Country:US
Practice Address - Phone:877-505-7147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-11
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-20916101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional