Provider Demographics
NPI:1619918620
Name:BLY, MARIE C (LCSW)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:C
Last Name:BLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1999
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37777
Mailing Address - Country:US
Mailing Address - Phone:865-970-1295
Mailing Address - Fax:865-380-1461
Practice Address - Street 1:2347 JONES BEND RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:TN
Practice Address - Zip Code:37777
Practice Address - Country:US
Practice Address - Phone:865-970-1295
Practice Address - Fax:865-380-1461
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3925187Medicare ID - Type Unspecified