Provider Demographics
NPI:1164289229
Name:BLANCO FERNANDEZ, JOHANNA
Entity Type:Individual
Prefix:MRS
First Name:JOHANNA
Middle Name:
Last Name:BLANCO FERNANDEZ
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 1:10000 NW 80TH CT APT 2549
Mailing Address - Street 2:
Mailing Address - City:HIALEAH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33016-2235
Mailing Address - Country:US
Mailing Address - Phone:786-689-6405
Mailing Address - Fax:
Practice Address - Street 1:10000 NW 80TH CT APT 2549
Practice Address - Street 2:
Practice Address - City:HIALEAH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33016-2235
Practice Address - Country:US
Practice Address - Phone:786-689-6405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-329577106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician