Provider Demographics
NPI:1225864812
Name:LEINAWEAVER, ELISE CORINNE
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:CORINNE
Last Name:LEINAWEAVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1238 COMMONWEALTH AVE APT 31
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02134-4215
Mailing Address - Country:US
Mailing Address - Phone:201-874-3647
Mailing Address - Fax:
Practice Address - Street 1:1238 COMMONWEALTH AVE APT 31
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02134-4215
Practice Address - Country:US
Practice Address - Phone:201-874-3647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist