Provider Demographics
NPI:1699363606
Name:BLEDSOE, DEMARRA
Entity Type:Individual
Prefix:
First Name:DEMARRA
Middle Name:
Last Name:BLEDSOE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1226 E NORTHSHORE DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-1410
Mailing Address - Country:US
Mailing Address - Phone:480-283-4674
Mailing Address - Fax:480-283-4674
Practice Address - Street 1:1226 E NORTHSHORE DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-1410
Practice Address - Country:US
Practice Address - Phone:480-283-4674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRBT-20-149007106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician