Provider Demographics
NPI:1053992917
Name:CARBALLO, BIANCA Y
Entity type:Individual
Prefix:
First Name:BIANCA
Middle Name:Y
Last Name:CARBALLO
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 1:18697 SW 297TH TER
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33030-2960
Mailing Address - Country:US
Mailing Address - Phone:786-417-2672
Mailing Address - Fax:
Practice Address - Street 1:4160 W 16TH AVE STE 502
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-5884
Practice Address - Country:US
Practice Address - Phone:786-401-7531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB625459106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician