Provider Demographics
NPI:1558872234
Name:BLANCO, LAURALYN ANN (OTR/L)
Entity Type:Individual
Prefix:
First Name:LAURALYN
Middle Name:ANN
Last Name:BLANCO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5063 AUGUST CT
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-2521
Mailing Address - Country:US
Mailing Address - Phone:510-909-8427
Mailing Address - Fax:
Practice Address - Street 1:5063 AUGUST CT
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-2521
Practice Address - Country:US
Practice Address - Phone:510-909-8427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-20
Last Update Date:2017-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT2267225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist