Provider Demographics
NPI:1477126746
Name:BEDOYA, FABIAN LEON
Entity Type:Individual
Prefix:
First Name:FABIAN
Middle Name:LEON
Last Name:BEDOYA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9216 DUBLIN GRN
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78254-5432
Mailing Address - Country:US
Mailing Address - Phone:210-792-9942
Mailing Address - Fax:
Practice Address - Street 1:9216 DUBLIN GRN
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78254-5432
Practice Address - Country:US
Practice Address - Phone:210-792-9942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38935101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX14799577OtherDRIVER LICENSE