Provider Demographics
NPI:1215611579
Name:BLANCHARD-VAN TASSEL, NICOLE MARIE (LADC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:BLANCHARD-VAN TASSEL
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 7TH ST NE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55906-3644
Mailing Address - Country:US
Mailing Address - Phone:507-512-3512
Mailing Address - Fax:
Practice Address - Street 1:343 WOODLAKE DR SE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55904-6242
Practice Address - Country:US
Practice Address - Phone:507-512-3512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN306310101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)