Provider Demographics
NPI:1154579902
Name:BLANCHARD, LESLIE A (PHD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
Last Name:BLANCHARD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 10323
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72812
Mailing Address - Country:US
Mailing Address - Phone:479-567-5654
Mailing Address - Fax:479-567-5661
Practice Address - Street 1:3101 WEST 2ND CT
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801
Practice Address - Country:US
Practice Address - Phone:479-567-5654
Practice Address - Fax:479-567-5661
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-05
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR07-7E103TC0700X
AR09-16P103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical