Provider Demographics
NPI:1215033212
Name:BLEDSOE, IVETTE LOPEZ (LCSW)
Entity Type:Individual
Prefix:MS
First Name:IVETTE
Middle Name:LOPEZ
Last Name:BLEDSOE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1341 ARIZONA BND
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-7774
Mailing Address - Country:US
Mailing Address - Phone:678-726-0211
Mailing Address - Fax:
Practice Address - Street 1:1360 CADUCEUS WAY BLDG 400
Practice Address - Street 2:SUITE 102
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-7300
Practice Address - Country:US
Practice Address - Phone:706-286-8442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6271041C0700X
GACSW0058011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical