Provider Demographics
NPI:1619347234
Name:BLANDFORD, KRISSY (MSP)
Entity Type:Individual
Prefix:
First Name:KRISSY
Middle Name:
Last Name:BLANDFORD
Suffix:
Gender:F
Credentials:MSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 W RUSH RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-3620
Mailing Address - Country:US
Mailing Address - Phone:208-921-1809
Mailing Address - Fax:
Practice Address - Street 1:1014 W RUSH RD
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-3620
Practice Address - Country:US
Practice Address - Phone:208-921-1809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-25
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)