Provider Demographics
NPI:1477697076
Name:LEBLANC, STEPHEN
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:
Last Name:LEBLANC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-1715
Mailing Address - Country:US
Mailing Address - Phone:508-791-8740
Mailing Address - Fax:508-752-3716
Practice Address - Street 1:173 GROVE ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-1715
Practice Address - Country:US
Practice Address - Phone:508-791-8740
Practice Address - Fax:508-752-3716
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10258225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA626330OtherHARVARD PILGRIM
MA981075OtherNETWORK HEALTH
MA729323OtherCONNECTICARE
MA459035OtherTUFTS
MA1477697076OtherBLUE CROSS
MA9645094OtherAETNA
MA000339301Medicare PIN