Provider Demographics
NPI:1508499609
Name:BLANCO, ROSALINA
Entity Type:Individual
Prefix:
First Name:ROSALINA
Middle Name:
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 1:1620 NW 78TH WAY
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-5166
Mailing Address - Country:US
Mailing Address - Phone:954-235-1116
Mailing Address - Fax:
Practice Address - Street 1:1620 NW 78TH WAY
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-5166
Practice Address - Country:US
Practice Address - Phone:954-235-1116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-17
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst