Provider Demographics
NPI:1346610318
Name:LEBLANC, DOMONIQUE
Entity type:Individual
Prefix:
First Name:DOMONIQUE
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 1:2200 VETERANS MEMORIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70062-4001
Mailing Address - Country:US
Mailing Address - Phone:504-305-4704
Mailing Address - Fax:504-305-4709
Practice Address - Street 1:2200 VETERANS MEMORIAL BLVD
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70062-4001
Practice Address - Country:US
Practice Address - Phone:504-305-4704
Practice Address - Fax:504-305-4709
Is Sole Proprietor?:No
Enumeration Date:2015-10-02
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA0000000000000Medicaid