Provider Demographics
NPI:1437506367
Name:GANDIA BLANCO, ADELINE
Entity Type:Individual
Prefix:
First Name:ADELINE
Middle Name:
Last Name:GANDIA 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 1:10121 SW 35TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-3830
Mailing Address - Country:US
Mailing Address - Phone:786-873-6770
Mailing Address - Fax:
Practice Address - Street 1:10121 SW 35TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-3830
Practice Address - Country:US
Practice Address - Phone:786-873-6770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-20
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103K00000X
FL0-18-8744106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty