Provider Demographics
NPI:1326005356
Name:PANTAZE, BEDE AR (PHD)
Entity Type:Individual
Prefix:DR
First Name:BEDE
Middle Name:AR
Last Name:PANTAZE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 586
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:VA
Mailing Address - Zip Code:24555
Mailing Address - Country:US
Mailing Address - Phone:540-461-5555
Mailing Address - Fax:804-741-7900
Practice Address - Street 1:9702 GAYTON RD
Practice Address - Street 2:#181
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23238-4907
Practice Address - Country:US
Practice Address - Phone:804-741-7500
Practice Address - Fax:804-741-7900
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810002816103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007712537Medicaid
VA245585OtherBLUE CROSS PIN
VA007712537Medicaid