Provider Demographics
NPI:1992286157
Name:BLEDSOE, ELISABETH (COTA)
Entity type:Individual
Prefix:
First Name:ELISABETH
Middle Name:
Last Name:BLEDSOE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:BURKBURNETT
Mailing Address - State:TX
Mailing Address - Zip Code:76354-3030
Mailing Address - Country:US
Mailing Address - Phone:580-281-0762
Mailing Address - Fax:
Practice Address - Street 1:1119 S RED RIVER EXPY
Practice Address - Street 2:
Practice Address - City:BURKBURNETT
Practice Address - State:TX
Practice Address - Zip Code:76354-3714
Practice Address - Country:US
Practice Address - Phone:940-569-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX211453224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant