Provider Demographics
NPI:1184514879
Name:BLUNDRED, BLAKE (DPT)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:BLUNDRED
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3914 ESCOBA DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-6826
Mailing Address - Country:US
Mailing Address - Phone:469-407-9176
Mailing Address - Fax:
Practice Address - Street 1:8651 JOHN T WHITE RD STE 121
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76120-2766
Practice Address - Country:US
Practice Address - Phone:817-542-0714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-07
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1406802225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist