Provider Demographics
NPI:1477621621
Name:BLANCHARD, BRADFORD JON (PT MHA)
Entity Type:Individual
Prefix:
First Name:BRADFORD
Middle Name:JON
Last Name:BLANCHARD
Suffix:
Gender:M
Credentials:PT MHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 ENTERPRISE DRIVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074
Mailing Address - Country:US
Mailing Address - Phone:207-883-8133
Mailing Address - Fax:207-883-8226
Practice Address - Street 1:400 ENTERPRISE DRIVE
Practice Address - Street 2:SUITE 3
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074
Practice Address - Country:US
Practice Address - Phone:207-883-8133
Practice Address - Fax:207-883-8226
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT796225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
022643OtherBCBS
AA32558OtherHARVARD PILGRIM
ME246550099Medicaid
ME246550099Medicaid