Healthcare Provider Details

I. General information

NPI: 1568690402
Provider Name (Legal Business Name): TARA LEBLANC MOT, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 09/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6401 BLUEBONNET BLVD SUITE 2192
BATON ROUGE LA
70836-6401
US

IV. Provider business mailing address

7278 CAHABA VALLEY RD #1435B
BIRMINGHAM AL
35242-6485
US

V. Phone/Fax

Practice location:
  • Phone: 708-352-6900
  • Fax:
Mailing address:
  • Phone: 225-772-9290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056008135
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number1615-648T
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: