Provider Demographics
NPI:1104178219
Name:BLANCHARD, MICHAEL (LADC-II)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BLANCHARD
Suffix:
Gender:M
Credentials:LADC-II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 852
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:MA
Mailing Address - Zip Code:02631-0852
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:745 HARWICH RD
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:MA
Practice Address - Zip Code:02631-2536
Practice Address - Country:US
Practice Address - Phone:774-994-0412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-12
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2277101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)