Provider Demographics
NPI:1982261921
Name:MAAL-BARED, LEITH
Entity Type:Individual
Prefix:
First Name:LEITH
Middle Name:
Last Name:MAAL-BARED
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 CAMELOT COURT
Mailing Address - Street 2:APARTMENT # 7-D
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135
Mailing Address - Country:US
Mailing Address - Phone:781-824-0170
Mailing Address - Fax:
Practice Address - Street 1:1416-410 QUEENS QUAY W.
Practice Address - Street 2:
Practice Address - City:TORONTO
Practice Address - State:ON
Practice Address - Zip Code:M5V3T1
Practice Address - Country:CA
Practice Address - Phone:647-453-4844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-24
Last Update Date:2020-02-06
Deactivation Date:2020-01-13
Deactivation Code:
Reactivation Date:2020-02-06
Provider Licenses
StateLicense IDTaxonomies
MA390200000X
MADL14106390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
105848OtherRCDSO