Provider Demographics
NPI:1124667761
Name:BLANCO, ALLISON KATHERYN
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:KATHERYN
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 1:9756 GLEN HERON DR
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-7773
Mailing Address - Country:US
Mailing Address - Phone:239-963-6002
Mailing Address - Fax:
Practice Address - Street 1:350 E BLOOMINGDALE AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-8155
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-30
Last Update Date:2024-03-05
Deactivation Date:2024-01-30
Deactivation Code:
Reactivation Date:2024-02-20
Provider Licenses
StateLicense IDTaxonomies
FL12258543103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst