Provider Demographics
NPI:1386745859
Name:BLASCO, LAURA (PT)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:
Last Name:BLASCO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8732 ROYALHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:NORTH ROYALTON
Mailing Address - State:OH
Mailing Address - Zip Code:44133-1657
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5273 BROADVIEW RD
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44134-1626
Practice Address - Country:US
Practice Address - Phone:216-749-6650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT-11086225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0842995Medicaid
OH34-1627933OtherTRICARE
OHOH4655AOtherBEECH STREET CORPORATION
OH000000217473OtherANTHEMBLUECROSS/BLUESHIEL
OHOH4655AOtherBEECH STREET CORPORATION
OH366587Medicare PIN