Healthcare Provider Details

I. General information

NPI: 1831222827
Provider Name (Legal Business Name): DEBRA S BLEDSOE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DEBRA S SHIVELY LCSW

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 01/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29861 FLORIDA AVE
ELKHART IN
46516-1351
US

IV. Provider business mailing address

29861 FLORIDA AVENUE
ELKHART IN
46516
US

V. Phone/Fax

Practice location:
  • Phone: 574-607-1110
  • Fax: 574-607-1110
Mailing address:
  • Phone: 574-607-1110
  • Fax: 574-607-1110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: