Provider Demographics
NPI:1275195893
Name:LEBLANC, ALICIA MARIE (OTA)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:MARIE
Last Name:LEBLANC
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 CUSHMAN DR
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-2314
Mailing Address - Country:US
Mailing Address - Phone:860-992-4299
Mailing Address - Fax:
Practice Address - Street 1:66 BROAD ST
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:MA
Practice Address - Zip Code:01085-2927
Practice Address - Country:US
Practice Address - Phone:413-562-5464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-03
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1987224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant