Provider Demographics
NPI:1942400304
Name:BLANCO, JOEL (PT)
Entity Type:Individual
Prefix:MR
First Name:JOEL
Middle Name:
Last Name:BLANCO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15800 MIDWAY RD
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-4259
Mailing Address - Country:US
Mailing Address - Phone:972-720-7915
Mailing Address - Fax:972-720-7778
Practice Address - Street 1:8267 ELMBROOK
Practice Address - Street 2:SUITE 101
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247-4030
Practice Address - Country:US
Practice Address - Phone:214-630-2331
Practice Address - Fax:214-905-1323
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1167790225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist