Provider Demographics
NPI:1336347533
Name:RESILIA. LLC
Entity Type:Organization
Organization Name:RESILIA. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:IVETTE
Authorized Official - Middle Name:LOPEZ
Authorized Official - Last Name:BLEDSOE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:706-395-3091
Mailing Address - Street 1:1341 ARIZONA BND
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-7774
Mailing Address - Country:US
Mailing Address - Phone:678-726-0211
Mailing Address - Fax:970-315-3560
Practice Address - Street 1:1 HUNTINGTON RD STE 205
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-7206
Practice Address - Country:US
Practice Address - Phone:706-395-3091
Practice Address - Fax:970-315-3560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO627251S00000X
GACSW005801251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOB4637Medicare PIN