Provider Demographics
NPI:1528535192
Name:BLASCO ESTEVES, LEIDYMAR JOHANA
Entity Type:Individual
Prefix:
First Name:LEIDYMAR
Middle Name:JOHANA
Last Name:BLASCO ESTEVES
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 1:162 MAGIC LANDINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-5514
Mailing Address - Country:US
Mailing Address - Phone:407-492-2392
Mailing Address - Fax:
Practice Address - Street 1:222 BROADWAY
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-5781
Practice Address - Country:US
Practice Address - Phone:407-329-3464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-31
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-69285106S00000X
FL0-21-13391106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician