Provider Demographics
NPI:1093221129
Name:BLY, TERRI E (PSYD, LP)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:E
Last Name:BLY
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:TERRI
Other - Middle Name:JOY
Other - Last Name:ELOFSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1150 MONTREAL AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-2393
Mailing Address - Country:US
Mailing Address - Phone:651-313-8080
Mailing Address - Fax:651-433-7122
Practice Address - Street 1:1150 MONTREAL AVE STE 107
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-2393
Practice Address - Country:US
Practice Address - Phone:651-313-8080
Practice Address - Fax:651-433-7122
Is Sole Proprietor?:No
Enumeration Date:2017-12-27
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4864103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily