Provider Demographics
NPI:1851076798
Name:BLANCO, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:BLANCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17950 SW 146TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-7671
Mailing Address - Country:US
Mailing Address - Phone:786-731-8483
Mailing Address - Fax:
Practice Address - Street 1:17950 SW 146TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177-7671
Practice Address - Country:US
Practice Address - Phone:786-731-8483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23277689106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician