Provider Demographics
NPI:1164200226
Name:LEELUM, NICHOLAS A (DPT)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:A
Last Name:LEELUM
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-2446
Mailing Address - Country:US
Mailing Address - Phone:516-474-9426
Mailing Address - Fax:
Practice Address - Street 1:217 WILSON ST
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA PARK
Practice Address - State:NY
Practice Address - Zip Code:11762-2446
Practice Address - Country:US
Practice Address - Phone:516-474-9426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-20
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050522225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist