Provider Demographics
NPI:1033873658
Name:BLANCO-LASTRE, JAIRON
Entity Type:Individual
Prefix:
First Name:JAIRON
Middle Name:
Last Name:BLANCO-LASTRE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2850 NW 173RD TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33056-4061
Mailing Address - Country:US
Mailing Address - Phone:305-299-4053
Mailing Address - Fax:
Practice Address - Street 1:2850 NW 173RD TER
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33056-4061
Practice Address - Country:US
Practice Address - Phone:305-299-4053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-29
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-190071106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician