Provider Demographics
NPI:1821308651
Name:BEDFORD, ERNEST ROBERT III (BA)
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:ROBERT
Last Name:BEDFORD
Suffix:III
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:SONNY
Other - Middle Name:
Other - Last Name:BEDFORD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BA
Mailing Address - Street 1:311 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILBURTON
Mailing Address - State:OK
Mailing Address - Zip Code:74578-4047
Mailing Address - Country:US
Mailing Address - Phone:918-465-0909
Mailing Address - Fax:
Practice Address - Street 1:311 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WILBURTON
Practice Address - State:OK
Practice Address - Zip Code:74578-4047
Practice Address - Country:US
Practice Address - Phone:918-465-0909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-14
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor