Provider Demographics
NPI:1992526651
Name:BLANCHARD, DOMINIQUE RENEE (LMT)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:RENEE
Last Name:BLANCHARD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 36TH STREET WEST
Mailing Address - Street 2:SUITE D
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205-2459
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:515 36TH STREET WEST
Practice Address - Street 2:STE D
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34205
Practice Address - Country:US
Practice Address - Phone:941-745-1313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-24
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA101902225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist