Provider Demographics
NPI:1548383136
Name:BEDKE-BERLIN, KHALI J (LCPC)
Entity Type:Individual
Prefix:
First Name:KHALI
Middle Name:J
Last Name:BEDKE-BERLIN
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 969
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-0969
Mailing Address - Country:US
Mailing Address - Phone:208-312-0470
Mailing Address - Fax:208-678-3556
Practice Address - Street 1:2311 PARK AVE
Practice Address - Street 2:UNIT 3 SUITE 12
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2170
Practice Address - Country:US
Practice Address - Phone:208-312-0470
Practice Address - Fax:208-678-3556
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-3490101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDQ7335OtherBLUE CROSS