Basic Information
| Provider Information | |||||||||
| NPI: | 1184117749 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAIKNER | ||||||||
| FirstName: | BIANCA | ||||||||
| MiddleName: | RAE | ||||||||
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| Credential: | LADC, LCMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 617 | ||||||||
| Address2: | |||||||||
| City: | ESSEX JUNCTION | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054530617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027343312 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 172 FAIRFIELD ST | ||||||||
| Address2: | |||||||||
| City: | SAINT ALBANS | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054781743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8024886900 | ||||||||
| FaxNumber: | 8024886919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2018 | ||||||||
| LastUpdateDate: | 04/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 151.0129115 | VT | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 068.0124899 | VT | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.