Provider Demographics
NPI:1144096074
Name:BLANCO, IYAIMA B
Entity type:Individual
Prefix:
First Name:IYAIMA
Middle Name:B
Last Name:BLANCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10810 SAKONNET RIVER DR APT 201
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-2992
Mailing Address - Country:US
Mailing Address - Phone:941-565-9164
Mailing Address - Fax:
Practice Address - Street 1:10810 SAKONNET RIVER DR APT 201
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-2992
Practice Address - Country:US
Practice Address - Phone:941-565-9164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-01
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23-311232106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician