Provider Demographics
NPI:1851946081
Name:BLANCHARD, CODY
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:BLANCHARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 492
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:IL
Mailing Address - Zip Code:61877-0492
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 W SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-4716
Practice Address - Country:US
Practice Address - Phone:217-398-8464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILB452-1019-0249104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker