Provider Demographics
NPI:1073277083
Name:RONNAU, BLAISE IGNACIOUS
Entity Type:Individual
Prefix:
First Name:BLAISE
Middle Name:IGNACIOUS
Last Name:RONNAU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2776 OUTRIDER CT
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-7512
Mailing Address - Country:US
Mailing Address - Phone:307-365-4475
Mailing Address - Fax:
Practice Address - Street 1:971 E WICHITA AVE
Practice Address - Street 2:
Practice Address - City:RUSSELL
Practice Address - State:KS
Practice Address - Zip Code:67665-2444
Practice Address - Country:US
Practice Address - Phone:785-657-7464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician