Healthcare Provider Details

I. General information

NPI: 1912556275
Provider Name (Legal Business Name): DESIRAE ANNE LEBLANC MSOT, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2019
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 MAIN ST
LEWISTON ME
04240-7041
US

IV. Provider business mailing address

486 METHODIST RD
WESTBROOK ME
04092-3207
US

V. Phone/Fax

Practice location:
  • Phone: 207-795-0111
  • Fax:
Mailing address:
  • Phone: 603-703-5164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT3729
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: