Provider Demographics
NPI:1205387214
Name:BLANCO, XIOMARA YAMILETH (MA)
Entity type:Individual
Prefix:
First Name:XIOMARA
Middle Name:YAMILETH
Last Name:BLANCO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11060 MAGNOLIA AVE.
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-3047
Mailing Address - Country:US
Mailing Address - Phone:951-358-6726
Mailing Address - Fax:
Practice Address - Street 1:11060 MAGNOLIA AVE.
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-3047
Practice Address - Country:US
Practice Address - Phone:951-358-6511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-14
Last Update Date:2024-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7488R101YA0400X
CA126809106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7488ROtherCAADE