Provider Demographics
NPI:1023899168
Name:BLY, KATHRYN ANNE
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ANNE
Last Name:BLY
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 1:5810 KINGSTOWNE CTR STE 120-239
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22315-5732
Mailing Address - Country:US
Mailing Address - Phone:989-600-2460
Mailing Address - Fax:
Practice Address - Street 1:8901 BATTERY RD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22308-2805
Practice Address - Country:US
Practice Address - Phone:989-600-2460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-12
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MI68011172381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical