Provider Demographics
NPI:1619140308
Name:LEISER, KATIE E (PT)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:E
Last Name:LEISER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:E
Other - Last Name:JANCZAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 727
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03766-0727
Mailing Address - Country:US
Mailing Address - Phone:603-643-7788
Mailing Address - Fax:603-643-0022
Practice Address - Street 1:112 ETNA RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766-1454
Practice Address - Country:US
Practice Address - Phone:603-643-7788
Practice Address - Fax:603-643-0022
Is Sole Proprietor?:No
Enumeration Date:2008-04-02
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT008176225100000X
NH3350225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH000685101OtherMEDICARE PTAN
NH3100041Medicaid