Provider Demographics
NPI:1164762258
Name:BEDFORD, MICHELLE RENE (COTA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENE
Last Name:BEDFORD
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:RENE
Other - Last Name:CHAPPELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:221 S UNION AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3490
Mailing Address - Country:US
Mailing Address - Phone:719-545-1114
Mailing Address - Fax:
Practice Address - Street 1:221 S UNION AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-3490
Practice Address - Country:US
Practice Address - Phone:719-545-1114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-26
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO100679251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health