Provider Demographics
NPI:1962432690
Name:MACRINA, LEONARD (PT)
Entity type:Individual
Prefix:
First Name:LEONARD
Middle Name:
Last Name:MACRINA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 CLEMATIS AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-7013
Mailing Address - Country:US
Mailing Address - Phone:617-992-2984
Mailing Address - Fax:
Practice Address - Street 1:110 CLEMATIS AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-7013
Practice Address - Country:US
Practice Address - Phone:617-992-2984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2017-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH4256225100000X
MA177062251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL7878489OtherAETNA
AL51530163OtherBCBS OF AL
AL890016400Medicaid