Provider Demographics
NPI:1457458101
Name:BEDEAUX, GRETCHEN KAY (PT)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:KAY
Last Name:BEDEAUX
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6020 CONSTITUTION AVE NE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-5900
Mailing Address - Country:US
Mailing Address - Phone:505-255-5099
Mailing Address - Fax:
Practice Address - Street 1:6020 CONSTITUTION AVE NE
Practice Address - Street 2:SUITE 4
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-5900
Practice Address - Country:US
Practice Address - Phone:505-255-5099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM539225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00071594Medicaid