Provider Demographics
NPI:1013663350
Name:BYFORD, BROOKA LOUISE (RBT)
Entity Type:Individual
Prefix:
First Name:BROOKA
Middle Name:LOUISE
Last Name:BYFORD
Suffix:
Gender:F
Credentials:RBT
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 2109
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-2109
Mailing Address - Country:US
Mailing Address - Phone:479-967-2322
Mailing Address - Fax:479-967-2876
Practice Address - Street 1:1301 RUSSELL RD
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72802-4320
Practice Address - Country:US
Practice Address - Phone:479-967-2322
Practice Address - Fax:479-967-2876
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-24
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARRBT-21-181640106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR273705706Medicaid