Provider Demographics
NPI:1841791324
Name:BLANCO, MCKAYLA MARIE (LSWAIC)
Entity Type:Individual
Prefix:
First Name:MCKAYLA
Middle Name:MARIE
Last Name:BLANCO
Suffix:
Gender:F
Credentials:LSWAIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 LILLY RD NE APT 335
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-7021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 LILLY RD NE APT 335
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-7021
Practice Address - Country:US
Practice Address - Phone:253-325-3213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC61171655104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker