Provider Demographics
NPI:1366868127
Name:LE BLANC, MARTHA J
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:J
Last Name:LE BLANC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-4000
Mailing Address - Country:US
Mailing Address - Phone:516-747-5644
Mailing Address - Fax:516-747-2556
Practice Address - Street 1:110 MAIN ST
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-4000
Practice Address - Country:US
Practice Address - Phone:516-747-5644
Practice Address - Fax:516-747-2556
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-17
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY11932103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)