Provider Demographics
NPI:1053108043
Name:BLANCO, ANA TAMARA
Entity type:Individual
Prefix:
First Name:ANA
Middle Name:TAMARA
Last Name:BLANCO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14264 SW 23RD ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-8023
Mailing Address - Country:US
Mailing Address - Phone:786-842-5912
Mailing Address - Fax:
Practice Address - Street 1:11401 SW 40TH ST STE 465
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-3340
Practice Address - Country:US
Practice Address - Phone:786-580-4609
Practice Address - Fax:786-580-4771
Is Sole Proprietor?:No
Enumeration Date:2025-04-22
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25417684106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician