Healthcare Provider Details

I. General information

NPI: 1033480389
Provider Name (Legal Business Name): SALLYBYROM PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2012
Last Update Date: 01/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8500 N MOPAC EXPY STE 501
AUSTIN TX
78759-8347
US

IV. Provider business mailing address

8500 N MOPAC EXPY STE 501
AUSTIN TX
78759-8347
US

V. Phone/Fax

Practice location:
  • Phone: 512-695-8979
  • Fax:
Mailing address:
  • Phone: 512-695-8979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number63448
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number201245
License Number StateTX

VIII. Authorized Official

Name: MRS. SALLY MILLER BYROM
Title or Position: OWNER
Credential: LPC, LMFT-ASSOCIATE
Phone: 512-695-8979