Provider Demographics
NPI:1407644560
Name:BLANCO LAGARES, SANTIAGO
Entity type:Individual
Prefix:
First Name:SANTIAGO
Middle Name:
Last Name:BLANCO LAGARES
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18015 NW 51ST PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33055-3229
Mailing Address - Country:US
Mailing Address - Phone:786-600-9643
Mailing Address - Fax:
Practice Address - Street 1:18015 NW 51ST PL
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33055-3229
Practice Address - Country:US
Practice Address - Phone:786-600-9643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25-428221106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician