Provider Demographics
NPI:1528202314
Name:BLANSETT, THOMAS ANDREW (PHD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ANDREW
Last Name:BLANSETT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 E SUNSHINE ST STE 318
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-1861
Mailing Address - Country:US
Mailing Address - Phone:417-886-4011
Mailing Address - Fax:417-886-4011
Practice Address - Street 1:2200 E SUNSHINE ST STE 318
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-1861
Practice Address - Country:US
Practice Address - Phone:417-886-4011
Practice Address - Fax:417-886-4011
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-24
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPYRO336103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1528202314Medicaid
MOMA1965Medicare PIN