Basic Information
| Provider Information | |||||||||
| NPI: | 1932116597 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEACU | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | PAMELA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 435 HARTFORD TPKE | ||||||||
| Address2: | SUITE U | ||||||||
| City: | VERNON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060664852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609791611 | ||||||||
| FaxNumber: | 2038663014 | ||||||||
| Practice Location | |||||||||
| Address1: | 435 HARTFORD TPKE | ||||||||
| Address2: | SUITE U | ||||||||
| City: | VERNON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060664852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8608708272 | ||||||||
| FaxNumber: | 8608750804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 02/01/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 17571 | MA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 008106 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.