Provider Demographics
NPI:1275307118
Name:LEEBRICK, BLAKE EDWARD (LSA)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:EDWARD
Last Name:LEEBRICK
Suffix:
Gender:M
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 BARCELONA LN
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-5415
Mailing Address - Country:US
Mailing Address - Phone:757-504-6741
Mailing Address - Fax:
Practice Address - Street 1:736 BATTLEFIELD BLVD N
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4941
Practice Address - Country:US
Practice Address - Phone:757-312-6151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-10
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0136000457246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant