Provider Demographics
NPI:1104680297
Name:BLANCO, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
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 1:1723 FOREST LAKES CIR
Mailing Address - Street 2:APT D
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33406-5745
Mailing Address - Country:US
Mailing Address - Phone:305-850-3338
Mailing Address - Fax:
Practice Address - Street 1:1723 FOREST LAKES CIR
Practice Address - Street 2:APT D
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33406-5745
Practice Address - Country:US
Practice Address - Phone:305-850-3338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-08
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-326278106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician