Basic Information
| Provider Information | |||||||||
| NPI: | 1679052948 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLANCHARD | ||||||||
| FirstName: | KAILA | ||||||||
| MiddleName: | RAE | ||||||||
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| Credential: | M.ED., BCBA, COBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 DEPAUW BLVD STE 3070 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462686135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553240885 | ||||||||
| FaxNumber: | 7654549759 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 INDIAN WOOD CIR STE 100 | ||||||||
| Address2: | |||||||||
| City: | MAUMEE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435374033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198300078 | ||||||||
| FaxNumber: | 7654549759 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2018 | ||||||||
| LastUpdateDate: | 08/08/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | COBA.00454 | OH | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 1-18-31007 | 01 | BCBA CERTIFICATE | OTHER |