Basic Information
| Provider Information | |||||||||
| NPI: | 1063903649 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLANDFORD | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | |||||||||
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| Credential: | BCBA, LBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 GRAYSON DR APT 1522 | ||||||||
| Address2: | |||||||||
| City: | GRAPEVINE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760517005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024980968 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12650 N BEACH ST STE 146 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762444253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8557827822 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2018 | ||||||||
| LastUpdateDate: | 09/01/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | OH | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | 5312 | TX | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.