Provider Demographics
NPI:1558042994
Name:BLANCO CARMONA, BRAYAN (RBT)
Entity Type:Individual
Prefix:
First Name:BRAYAN
Middle Name:
Last Name:BLANCO CARMONA
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4524 NW 191ST TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33055-2152
Mailing Address - Country:US
Mailing Address - Phone:305-504-0761
Mailing Address - Fax:
Practice Address - Street 1:4524 NW 191ST TER
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33055-2152
Practice Address - Country:US
Practice Address - Phone:305-504-0761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-28
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-278675106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty