Provider Demographics
NPI:1538441647
Name:LEBLANC, TIMOTHY PATRICK
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:PATRICK
Last Name:LEBLANC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 BUNNER ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-3357
Mailing Address - Country:US
Mailing Address - Phone:520-390-5118
Mailing Address - Fax:
Practice Address - Street 1:74 BUNNER ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-3357
Practice Address - Country:US
Practice Address - Phone:315-326-4100
Practice Address - Fax:315-326-4290
Is Sole Proprietor?:No
Enumeration Date:2011-09-14
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY091680104100000X
NY31975101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1336163963Medicaid