Provider Demographics
NPI:1790114429
Name:BLANCO, SHELLEY FORGAS (MS, CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:SHELLEY
Middle Name:FORGAS
Last Name:BLANCO
Suffix:
Gender:F
Credentials:MS, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19106 FISHERMANS BEND DR
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-9747
Mailing Address - Country:US
Mailing Address - Phone:813-401-0863
Mailing Address - Fax:
Practice Address - Street 1:19106 FISHERMANS BEND DR
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-9747
Practice Address - Country:US
Practice Address - Phone:813-401-0863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA12347235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist