Provider Demographics
NPI:1447543863
Name:PETERSON, LEELA (LMT)
Entity type:Individual
Prefix:
First Name:LEELA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 PLUMTREE DRIVE
Mailing Address - Street 2:UNIT C
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360
Mailing Address - Country:US
Mailing Address - Phone:860-705-8789
Mailing Address - Fax:
Practice Address - Street 1:10 COMMERCE ST STE A
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-4802
Practice Address - Country:US
Practice Address - Phone:860-705-8789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-18
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007630225700000X
MA9455173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist