Provider Demographics
NPI:1376502351
Name:LEBLANC, CLARK (PT)
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:
Last Name:LEBLANC
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 875
Mailing Address - Street 2:
Mailing Address - City:BREAUX BRIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70517-0875
Mailing Address - Country:US
Mailing Address - Phone:337-332-6120
Mailing Address - Fax:
Practice Address - Street 1:1220 BERARD ST
Practice Address - Street 2:SUITE B
Practice Address - City:BREAUX BRIDGE
Practice Address - State:LA
Practice Address - Zip Code:70517-4865
Practice Address - Country:US
Practice Address - Phone:337-332-6120
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1006225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA650016821 E0303OtherRAILROAD MEDICARE
LA1183605OtherCIGNA
LAB4436OtherBLUE CROSS/BLUE SHIELD
LA70517 A004OtherCHAMPUS
LA70517 A004OtherCHAMPUS