Provider Demographics
NPI:1932991247
Name:BLANCO PEREZ, DAMIAN JORGE
Entity type:Individual
Prefix:
First Name:DAMIAN
Middle Name:JORGE
Last Name:BLANCO PEREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4440 NW 9TH ST APT 28
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-2436
Mailing Address - Country:US
Mailing Address - Phone:305-505-3854
Mailing Address - Fax:
Practice Address - Street 1:4440 NW 9TH ST APT 28
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-2436
Practice Address - Country:US
Practice Address - Phone:305-505-3854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-21
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25-435737106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician