Provider Demographics
NPI:1447074463
Name:BLANCO PEISON, SUSET
Entity type:Individual
Prefix:
First Name:SUSET
Middle Name:
Last Name:BLANCO PEISON
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 1:777 NW 72ND AVE STE 1083
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-3176
Mailing Address - Country:US
Mailing Address - Phone:305-342-7643
Mailing Address - Fax:
Practice Address - Street 1:8820 NW 113TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33018-4527
Practice Address - Country:US
Practice Address - Phone:305-297-7950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-15
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician