Provider Demographics
NPI:1255519369
Name:LE BLANC, RENISE
Entity type:Individual
Prefix:
First Name:RENISE
Middle Name:
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 1:1704 W MANCHESTER AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90047-3056
Mailing Address - Country:US
Mailing Address - Phone:323-751-4778
Mailing Address - Fax:
Practice Address - Street 1:1704 W MANCHESTER AVE STE 103
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90047-3056
Practice Address - Country:US
Practice Address - Phone:323-751-4778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4772OtherCARR