Provider Demographics
NPI:1083044150
Name:BLANCO, LOURDES
Entity Type:Individual
Prefix:
First Name:LOURDES
Middle Name:
Last Name:BLANCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 COX AVE
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10704-3910
Mailing Address - Country:US
Mailing Address - Phone:914-564-5460
Mailing Address - Fax:
Practice Address - Street 1:58 COX AVE
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10704-3910
Practice Address - Country:US
Practice Address - Phone:914-564-5460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-26
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
NY1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty