Provider Demographics
NPI:1043764210
Name:BLANCHARD, STEPHANIE ANNE GWIN (OTR/L)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANNE GWIN
Last Name:BLANCHARD
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 NE LOOP 820
Mailing Address - Street 2:BUSINESS TOWER 1, SUITE 200
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053-7209
Mailing Address - Country:US
Mailing Address - Phone:817-292-8787
Mailing Address - Fax:817-789-6849
Practice Address - Street 1:3721 EXECUTIVE CENTER DR
Practice Address - Street 2:SUITE 201
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-1645
Practice Address - Country:US
Practice Address - Phone:512-372-3777
Practice Address - Fax:512-372-3336
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-05
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117764225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist