Healthcare Provider Details

I. General information

NPI: 1942255104
Provider Name (Legal Business Name): BEDFORD HINES M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 W. COLLEGE AVE. SUITE 815
APPLETON WI
54911
US

IV. Provider business mailing address

103 W. COLLEGE AVE. SUITE 815
APPLETON WI
54911
US

V. Phone/Fax

Practice location:
  • Phone: 920-733-1992
  • Fax: 920-733-1866
Mailing address:
  • Phone: 920-733-1992
  • Fax: 920-733-1866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2236125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: