Healthcare Provider Details

I. General information

NPI: 1073219853
Provider Name (Legal Business Name): CARLY ANNE LEUSNER MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2023
Last Update Date: 02/03/2023
Certification Date: 02/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 TROUBLE ST
CUMMINGTON MA
01026-9709
US

IV. Provider business mailing address

48 TROUBLE ST
CUMMINGTON MA
01026-9709
US

V. Phone/Fax

Practice location:
  • Phone: 413-588-6881
  • Fax:
Mailing address:
  • Phone: 413-588-6881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: