1740965037 NPI number — BRANDEE GRACE BLY MS, NCC, LPC

Table of content: BRANDEE GRACE BLY MS, NCC, LPC (NPI 1740965037)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740965037 NPI number — BRANDEE GRACE BLY MS, NCC, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLY
Provider First Name:
BRANDEE
Provider Middle Name:
GRACE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, NCC, LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740965037
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2518 14TH AVE NE APT 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERTOWN
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57201-7393
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-610-6385
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
818 S BROADWAY STE 109&110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERTOWN
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57201-4861
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-610-6385
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/15/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  LPC20768 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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