Provider Demographics
NPI:1265800056
Name:BLY, BRANDY LEE (MA, TLLP)
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:LEE
Last Name:BLY
Suffix:
Gender:F
Credentials:MA, TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15030 TERRY RD
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MI
Mailing Address - Zip Code:48002-1213
Mailing Address - Country:US
Mailing Address - Phone:810-434-4948
Mailing Address - Fax:
Practice Address - Street 1:1655 E CARO RD
Practice Address - Street 2:
Practice Address - City:CARO
Practice Address - State:MI
Practice Address - Zip Code:48723-9319
Practice Address - Country:US
Practice Address - Phone:989-673-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-10
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016435103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist