Provider Demographics
NPI:1003998808
Name:LEBLANC, ELLERI WYATT (MSOTR/L)
Entity Type:Individual
Prefix:MS
First Name:ELLERI
Middle Name:WYATT
Last Name:LEBLANC
Suffix:
Gender:F
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1935 STATE ROAD 436 STE 1005
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-2244
Mailing Address - Country:US
Mailing Address - Phone:407-629-9455
Mailing Address - Fax:407-629-9138
Practice Address - Street 1:1935 STATE ROAD 436 STE 1005
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-2244
Practice Address - Country:US
Practice Address - Phone:407-629-9455
Practice Address - Fax:407-629-9138
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT10618225XP0200X
FLOT18517225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8881916100Medicaid