Provider Demographics
NPI:1619601564
Name:BLANCHARD, MIA
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:BLANCHARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1612 BARKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-1118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3309 S KINGSHIGHWAY BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-1101
Practice Address - Country:US
Practice Address - Phone:314-307-7785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-14
Last Update Date:2023-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health