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General NPI Number Information
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NPI Number | 1740965037
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Entity Type | Individual
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Provider Name | BRANDEE GRACE BLY MS, NCC, LPC
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Gender | Female
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Dates
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Enumeration Date | 06/15/2023
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Last Update Date | 06/15/2023
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Provider Practice Location Address
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Address Line | 818 S BROADWAY STE 109&110
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City | WATERTOWN
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State | SD
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Zip | 57201-4861
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Country | US
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Telephone | 605-610-6385
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Fax |
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Provider Business Mailing Address
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Address Line | 2518 14TH AVE NE APT 103
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City | WATERTOWN
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State | SD
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Zip | 57201-7393
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Country | US
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Telephone | 605-610-6385
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LPC20768
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License Number State | SD
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