Provider Demographics
NPI:1265044556
Name:BLANCHARD, MARK PEYTON (MA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:PEYTON
Last Name:BLANCHARD
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36540 JEFFERSON CT APT 10302
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48335-1937
Mailing Address - Country:US
Mailing Address - Phone:516-578-4296
Mailing Address - Fax:
Practice Address - Street 1:1777 AXTELL DR STE 100
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4400
Practice Address - Country:US
Practice Address - Phone:248-787-3831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6352000225103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist