Provider Demographics
NPI:1548930555
Name:BLANCO, EILEEN AMARILYS
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:AMARILYS
Last Name:BLANCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SYLEEN
Other - Middle Name:
Other - Last Name:BLANCO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:982 VINELAND PL
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-1824
Mailing Address - Country:US
Mailing Address - Phone:407-925-4498
Mailing Address - Fax:
Practice Address - Street 1:1107 MABBETTE ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-5161
Practice Address - Country:US
Practice Address - Phone:407-201-8079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-20
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT22273225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist