Provider Demographics
NPI:1467125385
Name:BYRD, MALCOLM BASIL II (LCSW, CHES)
Entity Type:Individual
Prefix:MR
First Name:MALCOLM
Middle Name:BASIL
Last Name:BYRD
Suffix:II
Gender:M
Credentials:LCSW, CHES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 950244
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0244
Mailing Address - Country:US
Mailing Address - Phone:502-953-4700
Mailing Address - Fax:
Practice Address - Street 1:2215 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40212-1033
Practice Address - Country:US
Practice Address - Phone:502-774-8631
Practice Address - Fax:502-772-8189
Is Sole Proprietor?:No
Enumeration Date:2021-07-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2556311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical