Provider Demographics
NPI:1780957795
Name:BLETSON, FREDRICK THOMAS JR
Entity type:Individual
Prefix:
First Name:FREDRICK
Middle Name:THOMAS
Last Name:BLETSON
Suffix:JR
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:PO BOX 1753
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-1753
Mailing Address - Country:US
Mailing Address - Phone:425-876-0665
Mailing Address - Fax:
Practice Address - Street 1:2405 BAKER AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3118
Practice Address - Country:US
Practice Address - Phone:425-876-0665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-22
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACL60152626101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health