Basic Information
| Provider Information | |||||||||
| NPI: | 1972745610 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLANCHARD | ||||||||
| FirstName: | LARA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA,BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 440 EDMOND DR | ||||||||
| Address2: | |||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463111523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193221415 | ||||||||
| FaxNumber: | 2193221414 | ||||||||
| Practice Location | |||||||||
| Address1: | 440 EDMOND DR | ||||||||
| Address2: | |||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463111523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193221415 | ||||||||
| FaxNumber: | 2193221414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2009 | ||||||||
| LastUpdateDate: | 03/26/2009 | ||||||||
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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 | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.