Healthcare Provider Details

I. General information

NPI: 1215239322
Provider Name (Legal Business Name): MARISSA BLANCO LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2010
Last Update Date: 11/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 W PROSPECT RD Y&F
FT LAUDERDALE FL
33309-2519
US

IV. Provider business mailing address

2900 W PROSPECT RD Y&F
FT LAUDERDALE FL
33309-2519
US

V. Phone/Fax

Practice location:
  • Phone: 954-497-3856
  • Fax: 954-497-3857
Mailing address:
  • Phone: 954-497-3856
  • Fax: 954-497-3857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH10409
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: