Healthcare Provider Details

I. General information

NPI: 1992928469
Provider Name (Legal Business Name): CHARLES WILLIAM BLANCHARD PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 01/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3205 ARROWHEAD RD
LAS CRUCES NM
88011-4786
US

IV. Provider business mailing address

3205 ARROWHEAD RD
LAS CRUCES NM
88011-4786
US

V. Phone/Fax

Practice location:
  • Phone: 575-521-1725
  • Fax: 575-521-1725
Mailing address:
  • Phone: 575-521-1725
  • Fax: 575-521-1725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number622
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: