Provider Demographics
NPI:1962134064
Name:BLALOCK, LESLIE ELIZABETH (OTA/L)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:ELIZABETH
Last Name:BLALOCK
Suffix:
Gender:F
Credentials:OTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4212 CORAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-3016
Mailing Address - Country:US
Mailing Address - Phone:123-428-8759
Mailing Address - Fax:912-342-8016
Practice Address - Street 1:130 N GROSS RD STE 125
Practice Address - Street 2:
Practice Address - City:KINGSLAND
Practice Address - State:GA
Practice Address - Zip Code:31548-6263
Practice Address - Country:US
Practice Address - Phone:912-342-8875
Practice Address - Fax:912-342-8016
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA002877224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant