Healthcare Provider Details

I. General information

NPI: 1407189343
Provider Name (Legal Business Name): SUSANA BLANCO PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2009
Last Update Date: 11/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6175 NW 153RD ST STE 205
MIAMI LAKES FL
33014-2435
US

IV. Provider business mailing address

6175 NW 153RD ST STE 205
MIAMI LAKES FL
33014-2435
US

V. Phone/Fax

Practice location:
  • Phone: 305-814-8558
  • Fax:
Mailing address:
  • Phone: 305-814-8558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPY8411
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: