Provider Demographics
NPI:1295361806
Name:BYRUM, BRAD (MFT)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:BYRUM
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 E 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:LENNOX
Mailing Address - State:SD
Mailing Address - Zip Code:57039-2147
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:312 E 3RD AVE
Practice Address - Street 2:
Practice Address - City:LENNOX
Practice Address - State:SD
Practice Address - Zip Code:57039-2147
Practice Address - Country:US
Practice Address - Phone:650-676-7575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-14
Last Update Date:2020-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA118448106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000OtherI DON'T HAVE ANY SUCH NUMBERS