Healthcare Provider Details

I. General information

NPI: 1396282471
Provider Name (Legal Business Name): CRYSTAL RENEE BLANCHARD MA. LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2017
Last Update Date: 03/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 LOG CANOE CIR
STEVENSVILLE MD
21666-2127
US

IV. Provider business mailing address

201 PIGPEN POINT RD
QUEENSTOWN MD
21658-1158
US

V. Phone/Fax

Practice location:
  • Phone: 410-604-0226
  • Fax: 877-643-0126
Mailing address:
  • Phone: 410-304-2449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC7615
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: