Provider Demographics
NPI:1659913473
Name:BLANCO, LISSETTE
Entity Type:Individual
Prefix:
First Name:LISSETTE
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 1:9120 SW 143 AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186
Mailing Address - Country:US
Mailing Address - Phone:786-712-6836
Mailing Address - Fax:
Practice Address - Street 1:9120 SW 143 AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186
Practice Address - Country:US
Practice Address - Phone:786-712-6836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-14
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty