Basic Information
| Provider Information | |||||||||
| NPI: | 1841465085 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEBLANC | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | BLUM | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BLUM | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | LEA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 124 MALLARD ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296014046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642411040 | ||||||||
| FaxNumber: | 8642411049 | ||||||||
| Practice Location | |||||||||
| Address1: | 124 MALLARD ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296014046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642411040 | ||||||||
| FaxNumber: | 8642411049 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2008 | ||||||||
| LastUpdateDate: | 04/29/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 301100 | 05 | SC | MEDICAID |