Provider Demographics
NPI:1568731610
Name:BLEDSOE, MICHAEL LEE
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEE
Last Name:BLEDSOE
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 1:116 CIARA DR
Mailing Address - Street 2:
Mailing Address - City:MONTREAL
Mailing Address - State:MO
Mailing Address - Zip Code:65591-7801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:116 CIARA DR
Practice Address - Street 2:
Practice Address - City:MONTREAL
Practice Address - State:MO
Practice Address - Zip Code:65591-7801
Practice Address - Country:US
Practice Address - Phone:573-480-2378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO114979225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant