Healthcare Provider Details

I. General information

NPI: 1528552874
Provider Name (Legal Business Name): BRANDY J VAIL LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 N RUSSELL ST
MISSOULA MT
59801-1704
US

IV. Provider business mailing address

529 CAYUSE TRL
BOZEMAN MT
59718-8049
US

V. Phone/Fax

Practice location:
  • Phone: 406-532-8426
  • Fax: 406-224-4402
Mailing address:
  • Phone: 406-253-3743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberBBH-LCPC-LIC-30942
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: