Provider Demographics
NPI:1558191270
Name:BLANCO, AVERY LYNN
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:LYNN
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 1:3099 W CHAPMAN AVE APT 471
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-1739
Mailing Address - Country:US
Mailing Address - Phone:831-601-7606
Mailing Address - Fax:
Practice Address - Street 1:1100 W TOWN AND COUNTRY RD STE 1250
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4633
Practice Address - Country:US
Practice Address - Phone:657-339-2799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-06
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA147947106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1588424519OtherVILLAGES OF CALIFORNIA