Provider Demographics
NPI:1295716389
Name:BRADY, KRISTINE LYNN (PHD)
Entity type:Individual
Prefix:DR
First Name:KRISTINE
Middle Name:LYNN
Last Name:BRADY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 E MAIN ST
Mailing Address - Street 2:P.O. BOX 283
Mailing Address - City:VERMILLION
Mailing Address - State:SD
Mailing Address - Zip Code:57069-2201
Mailing Address - Country:US
Mailing Address - Phone:605-624-9307
Mailing Address - Fax:605-624-9308
Practice Address - Street 1:110 E MAIN ST
Practice Address - Street 2:
Practice Address - City:VERMILLION
Practice Address - State:SD
Practice Address - Zip Code:57069-2201
Practice Address - Country:US
Practice Address - Phone:605-624-9307
Practice Address - Fax:605-624-9308
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD455103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD28205OtherSIOUX VALLEY HEALTH PLAN
SD4995005OtherBLUE CROSS/BLUE SHIELD
SD6552222Medicaid
SD455OtherDAKOTACARE
SD100225Medicare ID - Type Unspecified