Provider Demographics
NPI:1982717211
Name:HULTSTROM, LEAH (PT, DPT)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:HULTSTROM
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 STABLE WAY
Mailing Address - Street 2:
Mailing Address - City:MEDWAY
Mailing Address - State:MA
Mailing Address - Zip Code:02053-6126
Mailing Address - Country:US
Mailing Address - Phone:617-759-8444
Mailing Address - Fax:
Practice Address - Street 1:165 MAIN ST UNIT 202A
Practice Address - Street 2:
Practice Address - City:MEDWAY
Practice Address - State:MA
Practice Address - Zip Code:02053-1584
Practice Address - Country:US
Practice Address - Phone:617-759-8444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPT105112251X0800X
MA10511MA2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY67284OtherBCBS INDIVIDUAL PROVIDER