Provider Demographics
NPI:1891736674
Name:LEBLANC-GRANT, JEANINE A (LADC)
Entity Type:Individual
Prefix:
First Name:JEANINE
Middle Name:A
Last Name:LEBLANC-GRANT
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:JEANNINE
Other - Middle Name:A
Other - Last Name:LEBLANC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LADC
Mailing Address - Street 1:1 STACKPOLE DR
Mailing Address - Street 2:
Mailing Address - City:MACHIAS
Mailing Address - State:ME
Mailing Address - Zip Code:04654-7000
Mailing Address - Country:US
Mailing Address - Phone:207-255-0996
Mailing Address - Fax:207-255-8748
Practice Address - Street 1:1 STACKPOLE DR
Practice Address - Street 2:
Practice Address - City:MACHIAS
Practice Address - State:ME
Practice Address - Zip Code:04654-7000
Practice Address - Country:US
Practice Address - Phone:207-255-0996
Practice Address - Fax:207-255-8748
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC 2539101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431773799Medicaid
ME431773799Medicaid