Healthcare Provider Details

I. General information

NPI: 1124667761
Provider Name (Legal Business Name): ALLISON KATHERYN BLANCO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2019
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date: 01/30/2024
Reactivation Date: 02/20/2024

III. Provider practice location address

7108 SOUTH KANNER HWY
STUART FL
34997
US

IV. Provider business mailing address

9756 GLEN HERON DR
BONITA SPRINGS FL
34135-7773
US

V. Phone/Fax

Practice location:
  • Phone: 855-832-6727
  • Fax:
Mailing address:
  • Phone: 239-963-6002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number12258543
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: