Provider Demographics
NPI:1932116597
Name:LEACU, PAMELA M (PT)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:M
Last Name:LEACU
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:435 HARTFORD TPKE
Mailing Address - Street 2:SUITE U
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-4852
Mailing Address - Country:US
Mailing Address - Phone:860-979-1611
Mailing Address - Fax:203-866-3014
Practice Address - Street 1:435 HARTFORD TPKE
Practice Address - Street 2:SUITE U
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-4852
Practice Address - Country:US
Practice Address - Phone:860-870-8272
Practice Address - Fax:860-875-0804
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17571225100000X
CT008106225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist