Provider Demographics
NPI:1992928469
Name:BLANCHARD, CHARLES WILLIAM (PHD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WILLIAM
Last Name:BLANCHARD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 ARROWHEAD RD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4786
Mailing Address - Country:US
Mailing Address - Phone:575-521-1725
Mailing Address - Fax:575-521-1725
Practice Address - Street 1:3205 ARROWHEAD RD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4786
Practice Address - Country:US
Practice Address - Phone:575-521-1725
Practice Address - Fax:575-521-1725
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM622103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000F4193Medicaid