1962612879 NPI number — MRS. LEESA A CONWAY MSPT

Table of content: MRS. LEESA A CONWAY MSPT (NPI 1962612879)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962612879 NPI number — MRS. LEESA A CONWAY MSPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONWAY
Provider First Name:
LEESA
Provider Middle Name:
A
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSPT
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:
1962612879
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/20/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 BOULDER POINT DR
Provider Second Line Business Mailing Address:
STE 3
Provider Business Mailing Address City Name:
PLYMOUTH
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03264-3170
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-536-5533
Provider Business Mailing Address Fax Number:
603-536-5550

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 BOULDER POINT DR
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
PLYMOUTH
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03264-3170
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-536-5533
Provider Business Practice Location Address Fax Number:
603-536-5550
Provider Enumeration Date:
05/23/2007

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: 225100000X , with the licence number:  11560 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 3191 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 30396921 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0326461 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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