Provider Demographics
NPI:1881767960
Name:BLANCHFIELD, MARYJANE
Entity type:Individual
Prefix:
First Name:MARYJANE
Middle Name:
Last Name:BLANCHFIELD
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 1:7535 54TH ST NE
Mailing Address - Street 2:
Mailing Address - City:PENN
Mailing Address - State:ND
Mailing Address - Zip Code:58362-9567
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:224 4TH ST NW
Practice Address - Street 2:SUITE 5
Practice Address - City:DEVILS LAKE
Practice Address - State:ND
Practice Address - Zip Code:58301-2960
Practice Address - Country:US
Practice Address - Phone:701-662-6776
Practice Address - Fax:701-662-6889
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND603101Y00000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND22354OtherBCBSND
ND19153Medicaid
ND58301-A002OtherTRIWEST
ND62-56618OtherMEDICA UBH
ND58301-A002OtherTRIWEST