Basic Information
| Provider Information | |||||||||
| NPI: | 1902304579 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLEDSOE | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GLENN | ||||||||
| OtherFirstName: | ASHLEY | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | BSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1050 NIAGARA ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142132007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168569711 | ||||||||
| FaxNumber: | 7168565614 | ||||||||
| Practice Location | |||||||||
| Address1: | 1050 NIAGARA ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142132007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168569711 | ||||||||
| FaxNumber: | 7168565614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2018 | ||||||||
| LastUpdateDate: | 01/29/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.