Provider Demographics
NPI:1235702721
Name:GAULT-BLANCHARD, SAMANTHA (RP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:GAULT-BLANCHARD
Suffix:
Gender:F
Credentials:RP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4480 RAY CIR APT A
Mailing Address - Street 2:
Mailing Address - City:FORT CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80902-1037
Mailing Address - Country:US
Mailing Address - Phone:602-218-1231
Mailing Address - Fax:
Practice Address - Street 1:6535 S DAYTON ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:80111-6125
Practice Address - Country:US
Practice Address - Phone:720-895-1000
Practice Address - Fax:720-895-8000
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0110852104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker