Provider Demographics
NPI:1407370224
Name:ENCISO-GONZALEZ, BLANCA
Entity Type:Individual
Prefix:
First Name:BLANCA
Middle Name:
Last Name:ENCISO-GONZALEZ
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 1:6675 MAMMOTH CAVE LN
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89156-4953
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6675 MAMMOTH CAVE LN
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89156-4953
Practice Address - Country:US
Practice Address - Phone:702-772-0670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-02
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst