Provider Demographics
NPI:1851791081
Name:BLANCQ, ROBERTA (PT)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:BLANCQ
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 1:319 W TOWN PL
Mailing Address - Street 2:SUITE 5
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-3101
Mailing Address - Country:US
Mailing Address - Phone:904-342-5262
Mailing Address - Fax:904-217-3580
Practice Address - Street 1:319 W TOWN PL
Practice Address - Street 2:SUITE 5
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-3101
Practice Address - Country:US
Practice Address - Phone:904-342-5262
Practice Address - Fax:904-217-3580
Is Sole Proprietor?:No
Enumeration Date:2014-08-25
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT21548225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist