Provider Demographics
NPI:1518925353
Name:BLANK, JULIE A (PT)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:A
Last Name:BLANK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:JULIE
Other - Middle Name:A
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:5968 CLARK CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34238-2715
Mailing Address - Country:US
Mailing Address - Phone:941-922-8200
Mailing Address - Fax:941-343-9402
Practice Address - Street 1:5968 CLARK CENTER AVE
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34238-2715
Practice Address - Country:US
Practice Address - Phone:941-922-8200
Practice Address - Fax:941-343-9402
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT19653225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY0469OtherBLUE CROSS & BLUE SHIELD
FLPT19653OtherPT LICENSE
FLP00052941OtherRR MEDICARE
FLPT19653OtherPT LICENSE
FLPT19653OtherPT LICENSE