Provider Demographics
NPI:1225480536
Name:BLANCHARD, BRANDON (MT)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:BLANCHARD
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2222
Mailing Address - Fax:
Practice Address - Street 1:5605 100TH ST SW
Practice Address - Street 2:STE. B
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-2710
Practice Address - Country:US
Practice Address - Phone:253-284-9800
Practice Address - Fax:253-284-9801
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60656978225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist