Provider Demographics
NPI:1245471952
Name:BLANCO, WANDA SIENA (LPCMH)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:SIENA
Last Name:BLANCO
Suffix:
Gender:F
Credentials:LPCMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:651 N BROAD ST STE 205 #4462
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-6402
Mailing Address - Country:US
Mailing Address - Phone:302-985-9831
Mailing Address - Fax:
Practice Address - Street 1:651 N BROAD ST STE 205 #4462
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-6402
Practice Address - Country:US
Practice Address - Phone:302-985-9831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-11
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC8003101YP2500X
DEPC0000797101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
13591550OtherCAQH ID