Healthcare Provider Details

I. General information

NPI: 1114387388
Provider Name (Legal Business Name): COURTNEY BLEDSOE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2016
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 CENTENARY BLVD STE 312
SHREVEPORT LA
71104-3358
US

IV. Provider business mailing address

745 KINGRIDGE PL
SHREVEPORT LA
71108-6017
US

V. Phone/Fax

Practice location:
  • Phone: 318-681-9935
  • Fax:
Mailing address:
  • Phone: 318-573-0872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6903
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: