Provider Demographics
NPI:1497886170
Name:LEISERSON, ANNE Q (MED)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:Q
Last Name:LEISERSON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 WINSLOW RD
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890-3017
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22 CHURCH ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149-2718
Practice Address - Country:US
Practice Address - Phone:781-306-4833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA171746101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool