Provider Demographics
NPI:1568690402
Name:LEBLANC, TARA (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:LEBLANC
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7278 CAHABA VALLEY RD
Mailing Address - Street 2:#1435B
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-6485
Mailing Address - Country:US
Mailing Address - Phone:225-772-9290
Mailing Address - Fax:
Practice Address - Street 1:6401 BLUEBONNET BLVD
Practice Address - Street 2:SUITE 2192
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70836-6401
Practice Address - Country:US
Practice Address - Phone:708-352-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2011-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056008135225X00000X
LA1615-648T152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL056008135Medicaid