Provider Demographics
NPI:1114387388
Name:BLEDSOE, COURTNEY
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:BLEDSOE
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 1:745 KINGRIDGE PL
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71108-6017
Mailing Address - Country:US
Mailing Address - Phone:318-573-0872
Mailing Address - Fax:
Practice Address - Street 1:2620 CENTENARY BLVD STE 312
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-3358
Practice Address - Country:US
Practice Address - Phone:318-681-9935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-02
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6903101YP2500X
LA104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker