Provider Demographics
NPI:1205232717
Name:BEDKE, CARSON J (LPC)
Entity Type:Individual
Prefix:
First Name:CARSON
Middle Name:J
Last Name:BEDKE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4319 W ROSE HILL CT
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-1361
Mailing Address - Country:US
Mailing Address - Phone:208-681-4186
Mailing Address - Fax:
Practice Address - Street 1:4319 W ROSE HILL CT
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1361
Practice Address - Country:US
Practice Address - Phone:208-681-4186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-10
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID5624101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health