Basic Information
| Provider Information | |||||||||
| NPI: | 1710966833 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEBLANC | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PHYSICAL THERAPIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11481 SW HALL BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972238403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002198835 | ||||||||
| FaxNumber: | 5034431402 | ||||||||
| Practice Location | |||||||||
| Address1: | 20055 SW PACIFIC HWY | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | SHERWOOD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971409294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036251691 | ||||||||
| FaxNumber: | 5039261460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2006 | ||||||||
| LastUpdateDate: | 06/18/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2684 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | QA0515100 | MA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 003918 | CT | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 278081 | 05 | OR | MEDICAID |