Provider Demographics
NPI:1972899631
Name:EDSTROM, BRUCE (LPC, LMFT)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:EDSTROM
Suffix:
Gender:M
Credentials:LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9401 LBJ FWY STE 420
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-4540
Mailing Address - Country:US
Mailing Address - Phone:469-688-3605
Mailing Address - Fax:
Practice Address - Street 1:9401 LBJ FWY STE 420
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-4540
Practice Address - Country:US
Practice Address - Phone:469-688-3605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-21
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10870101YP2500X
TX3880106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist