Provider Demographics
NPI:1811465644
Name:BLOEMENDAL, DUFFY (OTR)
Entity type:Individual
Prefix:MRS
First Name:DUFFY
Middle Name:
Last Name:BLOEMENDAL
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3920 HAMILTON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-1710
Mailing Address - Country:US
Mailing Address - Phone:214-587-5468
Mailing Address - Fax:
Practice Address - Street 1:4901 BRYANT IRVIN RD N STE 200
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-7673
Practice Address - Country:US
Practice Address - Phone:817-738-9866
Practice Address - Fax:817-817-3157
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-09
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109311225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation