Provider Demographics
NPI:1851451827
Name:BEDEKER, KENNETH
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:BEDEKER
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 1:5707 N 22ND STREET
Mailing Address - Street 2:MENTAL HEALTH CARE
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610
Mailing Address - Country:US
Mailing Address - Phone:813-272-2878
Mailing Address - Fax:813-272-3766
Practice Address - Street 1:7809 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34653-3028
Practice Address - Country:US
Practice Address - Phone:727-841-4200
Practice Address - Fax:813-834-3941
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13399101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL760925600Medicaid