Provider Demographics
NPI:1841779998
Name:MIGLIN, BLAKE (PT, DPT, OCS, CSCS)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:MIGLIN
Suffix:
Gender:M
Credentials:PT, DPT, OCS, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2650
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-8607
Mailing Address - Country:US
Mailing Address - Phone:972-724-2400
Mailing Address - Fax:972-724-2495
Practice Address - Street 1:4364 HERITAGE TRACE PKWY STE 108
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-9125
Practice Address - Country:US
Practice Address - Phone:817-379-1400
Practice Address - Fax:817-379-1404
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1308356225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist