Provider Demographics
NPI:1285352443
Name:BLANCO, RUDY ALBERT (LMFT)
Entity type:Individual
Prefix:
First Name:RUDY
Middle Name:ALBERT
Last Name:BLANCO
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3166 E PAINTED CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-7341
Mailing Address - Country:US
Mailing Address - Phone:626-262-0897
Mailing Address - Fax:
Practice Address - Street 1:405 W 5TH ST STE 212
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4522
Practice Address - Country:US
Practice Address - Phone:855-625-4657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA146354106H00000X
CA109285106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist