Provider Demographics
NPI:1073988069
Name:BLEDSOE, DENNIS DEAN JR (LBA, BCBA)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:DEAN
Last Name:BLEDSOE
Suffix:JR
Gender:M
Credentials:LBA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 ANTHONY ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-5806
Mailing Address - Country:US
Mailing Address - Phone:573-499-1362
Mailing Address - Fax:573-499-1362
Practice Address - Street 1:1506 ANTHONY ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-5806
Practice Address - Country:US
Practice Address - Phone:573-499-1362
Practice Address - Fax:573-499-1362
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013009326103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst