Healthcare Provider Details

I. General information

NPI: 1982717211
Provider Name (Legal Business Name): LEAH HULTSTROM PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 08/12/2021
Certification Date: 03/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 MAIN ST UNIT 202A
MEDWAY MA
02053-1584
US

IV. Provider business mailing address

17 STABLE WAY
MEDWAY MA
02053-6126
US

V. Phone/Fax

Practice location:
  • Phone: 617-759-8444
  • Fax:
Mailing address:
  • Phone: 617-759-8444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT10511
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number10511MA
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: