Healthcare Provider Details

I. General information

NPI: 1669268280
Provider Name (Legal Business Name): CARLY BRYAN MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 816
WILDER VT
05088-0816
US

IV. Provider business mailing address

PO BOX G
RANDOLPH VT
05060-0167
US

V. Phone/Fax

Practice location:
  • Phone: 802-728-4466
  • Fax: 802-728-4197
Mailing address:
  • Phone: 802-728-4466
  • Fax: 802-728-4197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number151.0134230
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: