Provider Demographics
NPI:1619480613
Name:BLEDSOE, ELIZABETH MAE (LCSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MAE
Last Name:BLEDSOE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4251 FOREST PARK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2810
Mailing Address - Country:US
Mailing Address - Phone:314-471-8220
Mailing Address - Fax:314-531-9731
Practice Address - Street 1:4251 FOREST PARK AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2810
Practice Address - Country:US
Practice Address - Phone:314-471-8220
Practice Address - Fax:314-531-9731
Is Sole Proprietor?:No
Enumeration Date:2017-11-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34007972A1041C0700X
NY0880031041C0700X
MO20220120431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2022012043OtherMO LCSW LICENSE