Provider Demographics
NPI:1235637067
Name:LEBLANC, CARLIE JO RICHARD (LCSW)
Entity Type:Individual
Prefix:
First Name:CARLIE
Middle Name:JO RICHARD
Last Name:LEBLANC
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 AUDUBON POINT DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-6442
Mailing Address - Country:US
Mailing Address - Phone:601-780-9074
Mailing Address - Fax:
Practice Address - Street 1:206 W JACKSON ST STE 100
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-2310
Practice Address - Country:US
Practice Address - Phone:601-780-9074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-26
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14645104100000X
171M00000X
MSC105401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator