Provider Demographics
NPI:1417554502
Name:MYCOFSKY, LEAH
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:MYCOFSKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:442 NASHUA ST
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03055-8903
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:442 NASHUA ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:NH
Practice Address - Zip Code:03055-4915
Practice Address - Country:US
Practice Address - Phone:603-673-9950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-02
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH4700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist