Provider Demographics
NPI:1427669076
Name:BRALLEY, ELIZABETH DUGGAN
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:DUGGAN
Last Name:BRALLEY
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 1:11713 N SHORE DR
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-4505
Mailing Address - Country:US
Mailing Address - Phone:703-740-7699
Mailing Address - Fax:
Practice Address - Street 1:5652 SHIELDS DR
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20817-3574
Practice Address - Country:US
Practice Address - Phone:240-225-0522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-16
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP10373101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1386161305OtherCAREFIRST BLUE CROSS BLUE SHIELD