Provider Demographics
NPI:1790307817
Name:BLANCO CABRERA, RAIMA DEL CARMEN
Entity Type:Individual
Prefix:
First Name:RAIMA
Middle Name:DEL CARMEN
Last Name:BLANCO CABRERA
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 1:15780 SW 206TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33187-1015
Mailing Address - Country:US
Mailing Address - Phone:305-801-4006
Mailing Address - Fax:
Practice Address - Street 1:12039 SW 132ND CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4783
Practice Address - Country:US
Practice Address - Phone:786-899-0308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-12
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-19-99389106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105812200Medicaid