Provider Demographics
NPI:1346759834
Name:VILLABLANCA, LAURYN MANDAC
Entity Type:Individual
Prefix:
First Name:LAURYN
Middle Name:MANDAC
Last Name:VILLABLANCA
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 1:4111 CONSOLIDATION AVE APT 103
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98229-2860
Mailing Address - Country:US
Mailing Address - Phone:425-306-4777
Mailing Address - Fax:
Practice Address - Street 1:1616 CORNWALL AVE STE 100
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-4642
Practice Address - Country:US
Practice Address - Phone:360-305-3275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-27
Last Update Date:2017-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPENDINGMedicaid