Provider Demographics
NPI:1073591194
Name:BLANZ, LARRY THEODORE (EDD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:THEODORE
Last Name:BLANZ
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 CHIMNEY HL
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37221-2219
Mailing Address - Country:US
Mailing Address - Phone:615-337-2026
Mailing Address - Fax:815-301-9511
Practice Address - Street 1:1900 CHURCH ST 300
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-2285
Practice Address - Country:US
Practice Address - Phone:615-337-2026
Practice Address - Fax:815-301-9511
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2015-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP 1037103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3684193Medicaid
TN3684193Medicaid