Provider Demographics
NPI:1821120668
Name:BRAGG, DANIELLE BLYTHE (LICSW)
Entity Type:Individual
Prefix:MS
First Name:DANIELLE
Middle Name:BLYTHE
Last Name:BRAGG
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 PATCHEN RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-5741
Mailing Address - Country:US
Mailing Address - Phone:802-865-9612
Mailing Address - Fax:
Practice Address - Street 1:1 LAWSON LN STE 310
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-8445
Practice Address - Country:US
Practice Address - Phone:802-343-8534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT08900010681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1012584Medicaid