Provider Demographics
NPI:1477978492
Name:WANTA, LEONARD (DPT)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:
Last Name:WANTA
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 1:535 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-5261
Mailing Address - Country:US
Mailing Address - Phone:781-961-3370
Mailing Address - Fax:781-767-7531
Practice Address - Street 1:1350 TREMONT ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02120-3447
Practice Address - Country:US
Practice Address - Phone:617-267-3773
Practice Address - Fax:617-602-1010
Is Sole Proprietor?:No
Enumeration Date:2014-02-27
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21013225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist