Provider Demographics
NPI:1942255104
Name:HINES, BEDFORD (MA)
Entity Type:Individual
Prefix:MR
First Name:BEDFORD
Middle Name:
Last Name:HINES
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 W. COLLEGE AVE.
Mailing Address - Street 2:SUITE 815
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911
Mailing Address - Country:US
Mailing Address - Phone:920-733-1992
Mailing Address - Fax:920-733-1866
Practice Address - Street 1:103 W. COLLEGE AVE.
Practice Address - Street 2:SUITE 815
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911
Practice Address - Country:US
Practice Address - Phone:920-733-1992
Practice Address - Fax:920-733-1866
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2236125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health