Healthcare Provider Details

I. General information

NPI: 1184588949
Provider Name (Legal Business Name): KYRA GLEASON
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CABOT RD FL 2
MEDFORD MA
02155-5117
US

IV. Provider business mailing address

13 6TH ST APT 2
CAMBRIDGE MA
02141-1173
US

V. Phone/Fax

Practice location:
  • Phone: 773-595-5250
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number10149
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: