Provider Demographics
NPI:1689118762
Name:LEONARD, CAITLIN (PTA)
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:
Last Name:LEONARD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 FARRAGUT AVE
Mailing Address - Street 2:1
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-1709
Mailing Address - Country:US
Mailing Address - Phone:781-354-8276
Mailing Address - Fax:
Practice Address - Street 1:5 MIDDLESEX AVE
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02145-1102
Practice Address - Country:US
Practice Address - Phone:617-591-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9228225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9228OtherPTA LICENSE