Provider Demographics
NPI:1508451782
Name:BLANCO, STEPHANIE DANIELLE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DANIELLE
Last Name: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 1:23502 LYONS AVE STE 304A
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91321-2538
Mailing Address - Country:US
Mailing Address - Phone:661-702-0166
Mailing Address - Fax:
Practice Address - Street 1:37654 MAUREEN ST
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-6812
Practice Address - Country:US
Practice Address - Phone:661-674-5849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician