Provider Demographics
NPI:1801077458
Name:BLANCHARD, GARY NORMAN (LADC1)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:NORMAN
Last Name:BLANCHARD
Suffix:
Gender:M
Credentials:LADC1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:683 DOUGLAS RD
Mailing Address - Street 2:
Mailing Address - City:WEST BROOKFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01585-6048
Mailing Address - Country:US
Mailing Address - Phone:413-627-9749
Mailing Address - Fax:
Practice Address - Street 1:4 SOUTH ST
Practice Address - Street 2:
Practice Address - City:WARE
Practice Address - State:MA
Practice Address - Zip Code:01082-1651
Practice Address - Country:US
Practice Address - Phone:413-627-9749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-23
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2188101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)