MEDICARE: CONNIE BLANCO OTR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	OT#460	OK
2	225XP0200X	Pediatric Occupational Therapist	OT#460	OK

General Provider Information

NPI Number	:	1104106269
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CONNIE BLANCO OTR

Provider Business Mailing Address
First Line	:	14715 BRISTOL PARK BLVD
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73013-1894
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9777 N COUNCIL RD APT 727
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73162-5551
Country	:	US
Telephone Number	:	405-474-6885
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2011
Last Update Date	:	08/31/2011

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Directions to “ CONNIE BLANCO OTR” Practice Location

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