Provider Demographics
NPI:1093312647
Name:BLANCO, RODY
Entity Type:Individual
Prefix:
First Name:RODY
Middle Name:
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 1:18512 FIELD CLUB WAY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-1823
Mailing Address - Country:US
Mailing Address - Phone:305-326-3415
Mailing Address - Fax:
Practice Address - Street 1:18512 FIELD CLUB WAY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-1823
Practice Address - Country:US
Practice Address - Phone:305-326-3415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-07
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst