Healthcare Provider Details

I. General information

NPI: 1336572502
Provider Name (Legal Business Name): BILL BEDFORD LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2013
Last Update Date: 08/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3490 LEXINGTON AVE N #205
SHOREVIEW MN
55126-8074
US

IV. Provider business mailing address

3490 LEXINGTON AVE N #205
SHOREVIEW MN
55126-8074
US

V. Phone/Fax

Practice location:
  • Phone: 651-486-3808
  • Fax: 651-486-3858
Mailing address:
  • Phone: 651-486-3808
  • Fax: 651-486-3858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: