Healthcare Provider Details

I. General information

NPI: 1205809902
Provider Name (Legal Business Name): CAROL A. LEAVELL PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 POND ST
BRAINTREE MA
02184-5351
US

IV. Provider business mailing address

250 POND ST
BRAINTREE MA
02184-5351
US

V. Phone/Fax

Practice location:
  • Phone: 781-348-2218
  • Fax: 781-348-2132
Mailing address:
  • Phone: 781-348-2218
  • Fax: 781-348-2132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number4712
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: