Provider Demographics
NPI:1063673754
Name:BLANCO, MARTIN (DACII)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:
Last Name:BLANCO
Suffix:
Gender:M
Credentials:DACII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:RED BLUFF
Mailing Address - State:CA
Mailing Address - Zip Code:96080-0400
Mailing Address - Country:US
Mailing Address - Phone:530-824-4890
Mailing Address - Fax:530-824-8443
Practice Address - Street 1:1600 SOLANO ST
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:CA
Practice Address - Zip Code:96021-2952
Practice Address - Country:US
Practice Address - Phone:530-824-4890
Practice Address - Fax:530-824-8443
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA3765798101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)