Provider Demographics
NPI:1043042526
Name:BLANCO, ROSEANNE SOFIA EVANGELISTA (OTR/L)
Entity type:Individual
Prefix:
First Name:ROSEANNE SOFIA
Middle Name:EVANGELISTA
Last Name:BLANCO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3822 MONTCLAIR ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90018-2363
Mailing Address - Country:US
Mailing Address - Phone:808-451-7049
Mailing Address - Fax:
Practice Address - Street 1:1932 14TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-4605
Practice Address - Country:US
Practice Address - Phone:310-344-2276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-14
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26770225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist