Provider Demographics
NPI:1841075801
Name:LEBLANC-MALLOY, ALY JEAN (OTR/L)
Entity type:Individual
Prefix:
First Name:ALY
Middle Name:JEAN
Last Name:LEBLANC-MALLOY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 SIERRA LN
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:ME
Mailing Address - Zip Code:04950-3928
Mailing Address - Country:US
Mailing Address - Phone:207-399-7648
Mailing Address - Fax:
Practice Address - Street 1:700 BIRCH LN
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583-2275
Practice Address - Country:US
Practice Address - Phone:573-774-6456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-29
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT4351225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty