Provider Demographics
NPI:1578571873
Name:BLEDSOE, ALICE MARIE (MED)
Entity Type:Individual
Prefix:MRS
First Name:ALICE
Middle Name:MARIE
Last Name:BLEDSOE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 N E ST
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-2627
Mailing Address - Country:US
Mailing Address - Phone:360-580-8696
Mailing Address - Fax:360-537-4659
Practice Address - Street 1:1104 N E ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-2627
Practice Address - Country:US
Practice Address - Phone:360-580-8696
Practice Address - Fax:360-537-4659
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00003514101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health