Provider Demographics
NPI:1215418231
Name:BLANCETT, DYLAN (DPT)
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:BLANCETT
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 1:2520 SAPPHIRE DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-2312
Mailing Address - Country:US
Mailing Address - Phone:719-930-4286
Mailing Address - Fax:
Practice Address - Street 1:1909 HINSON LOOP RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72212-3903
Practice Address - Country:US
Practice Address - Phone:501-301-4530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT4548225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist