Basic Information
| Provider Information | |||||||||
| NPI: | 1669105185 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEBLANG | ||||||||
| FirstName: | CHARLOTTE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21 BRADLEE RD APT 42 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021553154 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 41 MALL RD | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018050001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817445100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2022 | ||||||||
| LastUpdateDate: | 07/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 294048 | MA | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.