Healthcare Provider Details

I. General information

NPI: 1740812940
Provider Name (Legal Business Name): BRYANT BLANCHARD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2020
Last Update Date: 02/13/2020
Certification Date: 02/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 REES ST
BREAUX BRIDGE LA
70517-4611
US

IV. Provider business mailing address

251 REES ST
BREAUX BRIDGE LA
70517-4611
US

V. Phone/Fax

Practice location:
  • Phone: 337-442-6823
  • Fax: 337-442-6825
Mailing address:
  • Phone: 337-442-6823
  • Fax: 337-442-6825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: