Provider Demographics
NPI:1780918219
Name:LEBLANC, KELLY DONOVAN (MS OTR/L)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:DONOVAN
Last Name:LEBLANC
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 4TH ST
Mailing Address - Street 2:UNIT 441
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94107-1604
Mailing Address - Country:US
Mailing Address - Phone:781-838-2156
Mailing Address - Fax:
Practice Address - Street 1:300 PASTEUR DR
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-2200
Practice Address - Country:US
Practice Address - Phone:650-498-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-30
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10855174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist