Provider Demographics
NPI:1952644387
Name:BLEDSOE, ANDREA
Entity Type:Individual
Prefix:MS
First Name:ANDREA
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 1:3311 HERITAGE PKWY
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3189
Mailing Address - Country:US
Mailing Address - Phone:313-580-4516
Mailing Address - Fax:
Practice Address - Street 1:14799 DIX TOLEDO RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2507
Practice Address - Country:US
Practice Address - Phone:734-324-8326
Practice Address - Fax:734-324-8327
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-04
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802017601101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health