Healthcare Provider Details

I. General information

NPI: 1114548047
Provider Name (Legal Business Name): BRAD FITZGERALD LABASS LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2020
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2255 CHALLENGER WAY STE 107
SANTA ROSA CA
95407-5423
US

IV. Provider business mailing address

1305 EVERGREEN LN
PETALUMA CA
94954-5415
US

V. Phone/Fax

Practice location:
  • Phone: 707-565-4797
  • Fax: 707-565-4881
Mailing address:
  • Phone: 707-322-9994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number53462
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: