MEDICARE: MS. IVETTE LOPEZ BLEDSOE LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	627	CO
2	1041C0700X	Clinical Social Worker	CSW005801	GA

General Provider Information

NPI Number	:	1215033212
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. IVETTE LOPEZ BLEDSOE LCSW

Provider Business Mailing Address
First Line	:	1341 ARIZONA BND
Second Line	:
City	:	WATKINSVILLE
State	:	GA
Zip	:	30677-7774
Country	:	US
Telephone Number	:	678-726-0211
Fax Number	:

Provider Business Practice Location Address
First Line	:	1360 CADUCEUS WAY BLDG 400
Second Line	:	SUITE 102
City	:	WATKINSVILLE
State	:	GA
Zip	:	30677-7300
Country	:	US
Telephone Number	:	706-286-8442
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	09/02/2016

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