Provider Demographics
NPI:1073351177
Name:BLANCO, ALIUSNEIDIS
Entity type:Individual
Prefix:
First Name:ALIUSNEIDIS
Middle Name:
Last Name:BLANCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 NW 141ST AVE APT 106
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-2328
Mailing Address - Country:US
Mailing Address - Phone:786-458-5715
Mailing Address - Fax:
Practice Address - Street 1:950 NW 141ST AVE APT 106
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-2328
Practice Address - Country:US
Practice Address - Phone:786-458-5715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24-339585106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician