Provider Demographics
NPI:1700015179
Name:BLEDSOE, DEMOND E
Entity Type:Individual
Prefix:
First Name:DEMOND
Middle Name:E
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 1:221 PENN AVE
Mailing Address - Street 2:
Mailing Address - City:WILKINSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15221-2118
Mailing Address - Country:US
Mailing Address - Phone:412-342-2253
Mailing Address - Fax:
Practice Address - Street 1:221 PENN AVE
Practice Address - Street 2:
Practice Address - City:WILKINSBURG
Practice Address - State:PA
Practice Address - Zip Code:15221-2118
Practice Address - Country:US
Practice Address - Phone:412-319-7547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-07
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC004879101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional