Provider Demographics
NPI:1881075562
Name:TELLEZ, BLANCA IRASEMA
Entity type:Individual
Prefix:
First Name:BLANCA
Middle Name:IRASEMA
Last Name:TELLEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BLANCA
Other - Middle Name:IRASEMA
Other - Last Name:TELLEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:511 HAHAIONE ST APT 10C
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96825-1437
Mailing Address - Country:US
Mailing Address - Phone:808-927-7760
Mailing Address - Fax:
Practice Address - Street 1:511 HAHAIONE ST APT 10C
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96825-1437
Practice Address - Country:US
Practice Address - Phone:808-927-7760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-17
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
HIBA-823-0103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health