Provider Demographics
NPI:1003101445
Name:BLANCO, GRISELDA (OTR)
Entity Type:Individual
Prefix:
First Name:GRISELDA
Middle Name:
Last Name:BLANCO
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5346 E US HIGHWAY 83 STE 2
Mailing Address - Street 2:
Mailing Address - City:RIO GRANDE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78582-9418
Mailing Address - Country:US
Mailing Address - Phone:956-292-1700
Mailing Address - Fax:
Practice Address - Street 1:5346 E US HIGHWAY 83 STE 2
Practice Address - Street 2:
Practice Address - City:RIO GRANDE CITY
Practice Address - State:TX
Practice Address - Zip Code:78582-9418
Practice Address - Country:US
Practice Address - Phone:956-317-1282
Practice Address - Fax:956-317-1282
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2023-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114169225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX460581169Medicaid
TX270385434Medicaid
TX270230249Medicaid
TX862263137Medicaid