Provider Demographics
NPI:1811696206
Name:LEBLANC, AVERY
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:
Last Name:LEBLANC
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 1:3652 MICHELSON DR
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-1727
Mailing Address - Country:US
Mailing Address - Phone:949-474-1493
Mailing Address - Fax:
Practice Address - Street 1:4883 RONSON CT STE I
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-1812
Practice Address - Country:US
Practice Address - Phone:949-993-6987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-24
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician