Provider Demographics
NPI:1073114484
Name:BLANCO, CHRISTOPHER ADAM
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:ADAM
Last Name:BLANCO
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:PO BOX 1207
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98907-1207
Mailing Address - Country:US
Mailing Address - Phone:509-457-5653
Mailing Address - Fax:
Practice Address - Street 1:201 E LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98901-2348
Practice Address - Country:US
Practice Address - Phone:509-457-5653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61035934101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2077844Medicaid