Provider Demographics
NPI:1528552874
Name:VAIL, BRANDY J (LCPC)
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:J
Last Name:VAIL
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 CAYUSE TRL
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-8049
Mailing Address - Country:US
Mailing Address - Phone:406-253-3743
Mailing Address - Fax:
Practice Address - Street 1:140 N RUSSELL ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-1704
Practice Address - Country:US
Practice Address - Phone:406-532-8426
Practice Address - Fax:406-224-4402
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCPC-LIC-30942101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
14273561OtherCAQH