Provider Demographics
NPI:1235822438
Name:HERNANDEZ BLANCO, LISANDRA
Entity Type:Individual
Prefix:
First Name:LISANDRA
Middle Name:
Last Name:HERNANDEZ 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 1:510 15TH CT NE
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4333
Mailing Address - Country:US
Mailing Address - Phone:407-860-8845
Mailing Address - Fax:
Practice Address - Street 1:2243 NORTH BLVD W
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-8990
Practice Address - Country:US
Practice Address - Phone:863-270-1339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician