Healthcare Provider Details

I. General information

NPI: 1316780927
Provider Name (Legal Business Name): ANGEL BYRD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2024
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4903 82ND ST STE 60
LUBBOCK TX
79424-3123
US

IV. Provider business mailing address

PO BOX 748465
ATLANTA GA
30374-8465
US

V. Phone/Fax

Practice location:
  • Phone: 210-399-3252
  • Fax: 617-807-0958
Mailing address:
  • Phone: 855-284-7483
  • Fax: 617-807-0958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number84495
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: