Provider Demographics
NPI:1194108852
Name:LABRUM, ROBERT DALE (MA, NCC, LPC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:DALE
Last Name:LABRUM
Suffix:
Gender:M
Credentials:MA, NCC, LPC
Other - Prefix:
Other - First Name:R.
Other - Middle Name:DALE
Other - Last Name:LABRUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:PO BOX 13403
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85216-3403
Mailing Address - Country:US
Mailing Address - Phone:602-435-4356
Mailing Address - Fax:
Practice Address - Street 1:4111 E VALLEY AUTO DR STE 106
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4607
Practice Address - Country:US
Practice Address - Phone:602-435-4356
Practice Address - Fax:855-564-1725
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YP1600X, 101YP2500X, 101YM0800X
AZLPC17409101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ418668Medicaid