Provider Demographics
NPI:1376520221
Name:BLEDSOE, AMY K KISO (LPC, NCC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:K KISO
Last Name:BLEDSOE
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:K
Other - Last Name:KISO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 659
Mailing Address - Street 2:
Mailing Address - City:BELLE
Mailing Address - State:MO
Mailing Address - Zip Code:65013-0659
Mailing Address - Country:US
Mailing Address - Phone:573-943-2303
Mailing Address - Fax:573-943-2304
Practice Address - Street 1:901 N PINE ST
Practice Address - Street 2:SUITE 307
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-3141
Practice Address - Country:US
Practice Address - Phone:573-943-2303
Practice Address - Fax:573-943-2304
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000170900101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO131813OtherBLUE CROSS/BLUE SHIELD