Healthcare Provider Details

I. General information

NPI: 1245471952
Provider Name (Legal Business Name): WANDA SIENA BLANCO LPCMH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2009
Last Update Date: 02/09/2021
Certification Date: 02/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

651 N BROAD ST STE 205 #4462
MIDDLETOWN DE
19709-6402
US

IV. Provider business mailing address

651 N BROAD ST STE 205 #4462
MIDDLETOWN DE
19709-6402
US

V. Phone/Fax

Practice location:
  • Phone: 302-985-9831
  • Fax:
Mailing address:
  • Phone: 302-985-9831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPC0000797
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC8003
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: