Provider Demographics
NPI:1588969646
Name:BLANCHARD, BRUCE W (MSW)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:W
Last Name:BLANCHARD
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 K ST
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1441
Mailing Address - Country:US
Mailing Address - Phone:208-356-4845
Mailing Address - Fax:
Practice Address - Street 1:27 K ST
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1441
Practice Address - Country:US
Practice Address - Phone:208-356-4845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-8741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical