=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386182830
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAURA J. LEBLANC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2017
-----------------------------------------------------
Last Update Date | 02/05/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 727 CLARK CT
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53715-1421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-844-8389
-----------------------------------------------------
Fax | 773-681-7488
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 727 CLARK CT
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53715-1421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-844-8389
-----------------------------------------------------
Fax | 773-681-7488
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LCSW
-----------------------------------------------------
Name | LAURA LEBLANC
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-844-8389
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149010106
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 8521-123
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------