Healthcare Provider Details

I. General information

NPI: 1265044556
Provider Name (Legal Business Name): MARK PEYTON BLANCHARD PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2020
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1218 MASSACHUSETTS AVE STE 3
CAMBRIDGE MA
02138-3835
US

IV. Provider business mailing address

1218 MASSACHUSETTS AVE STE 3
CAMBRIDGE MA
02138-3835
US

V. Phone/Fax

Practice location:
  • Phone: 617-299-9913
  • Fax:
Mailing address:
  • Phone: 617-299-9913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY10000947
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: