Provider Demographics
NPI:1295344380
Name:BLANCO, KIMBERLY ROSE (MSW)
Entity type:Individual
Prefix:
First Name:KIMBERLY ROSE
Middle Name:
Last Name:BLANCO
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 FULTON AVE APT 2110
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-6446
Mailing Address - Country:US
Mailing Address - Phone:707-561-1449
Mailing Address - Fax:
Practice Address - Street 1:7273 14TH AVE STE 120B
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95820-3500
Practice Address - Country:US
Practice Address - Phone:916-383-6783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-24
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
CA96343104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator