Provider Demographics
NPI:1386644821
Name:BLANCO, MARISSA (LPC, FNP)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:BLANCO
Suffix:
Gender:F
Credentials:LPC, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 BROADWAY STE 5
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79401-3209
Mailing Address - Country:US
Mailing Address - Phone:806-765-2611
Mailing Address - Fax:806-741-3012
Practice Address - Street 1:1318 BROADWAY
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79401-3206
Practice Address - Country:US
Practice Address - Phone:806-765-2611
Practice Address - Fax:806-741-3012
Is Sole Proprietor?:No
Enumeration Date:2005-07-27
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10875101YM0800X
TX760444363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX028736901Medicaid