| Doctor Name: | MR. MARK R BLANCO |
| NPI Number: | 1174647226 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | M.A., SR. LPE |
| License Number: | PE0000011423 |
| Business Practice Address: | 1009 Ash Cir La Vergne, TN - 370864157 |
| Business Phone Number: | 6157936513 |
| Business Fax Number: | |
| Mailing Address: | 1009 Ash Cir, LA VERGNE |
| State: | TN |
| Postal Code: | 370864157 |
| Phone Number: | 6157936513 |
| Fax Number: | |
| NPI Enumeration Date: | 03/16/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YP2500X |
| License Number: | PE0000011423 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | TN |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Professional |
| Taxonomy Definition: | |