Provider Demographics
NPI:1528693736
Name:LEBLANC, CRYSTAL
Entity type:Individual
Prefix:
First Name:CRYSTAL
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 1:810 ONEAL LN
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-1805
Mailing Address - Country:US
Mailing Address - Phone:225-615-7555
Mailing Address - Fax:
Practice Address - Street 1:810 ONEAL LN
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-1805
Practice Address - Country:US
Practice Address - Phone:225-615-7555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-09
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAL772434766Medicaid