Provider Demographics
NPI:1235370701
Name:BLANCO, LISETTE (LMSW)
Entity Type:Individual
Prefix:MS
First Name:LISETTE
Middle Name:
Last Name:BLANCO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14220 84TH DR
Mailing Address - Street 2:5M
Mailing Address - City:BRIARWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11435-2152
Mailing Address - Country:US
Mailing Address - Phone:718-657-2950
Mailing Address - Fax:
Practice Address - Street 1:622 W 168TH ST
Practice Address - Street 2:VC-205 AIM CLINIC
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3720
Practice Address - Country:US
Practice Address - Phone:212-305-3078
Practice Address - Fax:212-305-6279
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-13
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0507811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical