MEDICARE: BLAKE BLUNDRED DPT

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	225100000X	Physical Therapist	1406802	TX

General Provider Information

NPI Number	:	1184514879
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BLAKE BLUNDRED DPT

Provider Business Mailing Address
First Line	:	3914 ESCOBA DR
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-6826
Country	:	US
Telephone Number	:	469-407-9176
Fax Number	:

Provider Business Practice Location Address
First Line	:	8651 JOHN T WHITE RD STE 121
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76120-2766
Country	:	US
Telephone Number	:	817-542-0714
Fax Number	:

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

Provider Enumeration Date	:	07/07/2025
Last Update Date	:	07/07/2025

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Directions to “ BLAKE BLUNDRED DPT” Practice Location

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