Provider Demographics
NPI:1073028304
Name:BLANCHARD, KIMBERLY (LPA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BLANCHARD
Suffix:
Gender:F
Credentials:LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 INTERSTATE 10 N STE 205
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-2114
Mailing Address - Country:US
Mailing Address - Phone:409-225-5796
Mailing Address - Fax:
Practice Address - Street 1:80 INTERSTATE 10 N STE 205
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-2114
Practice Address - Country:US
Practice Address - Phone:409-225-5796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-08
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37772103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist