Provider Demographics
NPI:1467212555
Name:BLANCO PINEDA, LILIAN GAUDY
Entity Type:Individual
Prefix:
First Name:LILIAN
Middle Name:GAUDY
Last Name:BLANCO PINEDA
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 1:2007 JOANS TER
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-3042
Mailing Address - Country:US
Mailing Address - Phone:407-412-2368
Mailing Address - Fax:
Practice Address - Street 1:2007 JOANS TER
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-3042
Practice Address - Country:US
Practice Address - Phone:407-412-2368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-328470106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician