Provider Demographics
NPI:1962612879
Name:CONWAY, LEESA A (MSPT)
Entity type:Individual
Prefix:MRS
First Name:LEESA
Middle Name:A
Last Name:CONWAY
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 BOULDER POINT DR
Mailing Address - Street 2:STE 3
Mailing Address - City:PLYMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03264-3170
Mailing Address - Country:US
Mailing Address - Phone:603-536-5533
Mailing Address - Fax:603-536-5550
Practice Address - Street 1:101 BOULDER POINT DR
Practice Address - Street 2:SUITE 3
Practice Address - City:PLYMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03264-3170
Practice Address - Country:US
Practice Address - Phone:603-536-5533
Practice Address - Fax:603-536-5550
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11560225100000X
NH3191225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30396921Medicaid
MA0326461Medicaid
MA0326461Medicaid
MARU Y69378Medicare ID - Type Unspecified