Healthcare Provider Details

I. General information

NPI: 1184514879
Provider Name (Legal Business Name): BLAKE BLUNDRED DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2025
Last Update Date: 07/07/2025
Certification Date: 07/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8651 JOHN T WHITE RD STE 121
FORT WORTH TX
76120-2766
US

IV. Provider business mailing address

3914 ESCOBA DR
GRAND PRAIRIE TX
75052-6826
US

V. Phone/Fax

Practice location:
  • Phone: 817-542-0714
  • Fax:
Mailing address:
  • Phone: 469-407-9176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1406802
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: