1962134064 NPI number — LESLIE ELIZABETH BLALOCK OTA/L

Table of content: LESLIE ELIZABETH BLALOCK OTA/L (NPI 1962134064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962134064 NPI number — LESLIE ELIZABETH BLALOCK OTA/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLALOCK
Provider First Name:
LESLIE
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTA/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962134064
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/28/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4212 CORAL PARK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRUNSWICK
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31520-3016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
123-428-8759
Provider Business Mailing Address Fax Number:
912-342-8016

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
130 N GROSS RD STE 125
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGSLAND
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31548-6263
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-342-8875
Provider Business Practice Location Address Fax Number:
912-342-8016
Provider Enumeration Date:
06/28/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 224Z00000X , with the licence number:  OTA002877 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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