Provider Demographics
NPI:1538035571
Name:BALTAZAR, BIANCA MONIQUE
Entity type:Individual
Prefix:MRS
First Name:BIANCA
Middle Name:MONIQUE
Last Name:BALTAZAR
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 1:100 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:GA
Mailing Address - Zip Code:30290-8001
Mailing Address - Country:US
Mailing Address - Phone:404-966-3933
Mailing Address - Fax:
Practice Address - Street 1:100 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290-8001
Practice Address - Country:US
Practice Address - Phone:404-966-3933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-16
Last Update Date:2025-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician