Provider Demographics
NPI:1770235012
Name:BRAGG, MARY BETH
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:BRAGG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 18TH AVE N STE 200
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-2253
Mailing Address - Country:US
Mailing Address - Phone:615-292-3661
Mailing Address - Fax:
Practice Address - Street 1:317 18TH AVE N STE 200
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-2253
Practice Address - Country:US
Practice Address - Phone:615-292-3661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-18
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN134898097OtherDRIVERS LICENSE