Provider Demographics
NPI:1679080386
Name:BLANCO, JOEL (PT)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:BLANCO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:JOEL
Other - Middle Name:D
Other - Last Name:BLANCO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ATC
Mailing Address - Street 1:336 BROAD ST STE 203
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-3006
Mailing Address - Country:US
Mailing Address - Phone:407-880-8438
Mailing Address - Fax:
Practice Address - Street 1:541 N PARK AVE
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32712-3654
Practice Address - Country:US
Practice Address - Phone:407-880-8438
Practice Address - Fax:407-880-9570
Is Sole Proprietor?:No
Enumeration Date:2018-01-03
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL38122255A2300X
FLPT36067225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer