Provider Demographics
NPI:1962266122
Name:BEDARD, ANNE MARIE (MA, TLLP)
Entity type:Individual
Prefix:MS
First Name:ANNE MARIE
Middle Name:
Last Name:BEDARD
Suffix:
Gender:F
Credentials:MA, TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2757 BUTTERNUT CT
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-1566
Mailing Address - Country:US
Mailing Address - Phone:313-515-1305
Mailing Address - Fax:
Practice Address - Street 1:2757 BUTTERNUT CT
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-1566
Practice Address - Country:US
Practice Address - Phone:313-515-1305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-08
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362009723103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist