Healthcare Provider Details

I. General information

NPI: 1851451827
Provider Name (Legal Business Name): KENNETH BEDEKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7809 MASSACHUSETTS AVE
NEW PORT RICHEY FL
34653-3028
US

IV. Provider business mailing address

5707 N 22ND STREET MENTAL HEALTH CARE
TAMPA FL
33610
US

V. Phone/Fax

Practice location:
  • Phone: 727-841-4200
  • Fax: 813-834-3941
Mailing address:
  • Phone: 813-272-2878
  • Fax: 813-272-3766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number13399
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: