Healthcare Provider Details

I. General information

NPI: 1386734572
Provider Name (Legal Business Name): JOHN J LEAHY EDD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 02/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NOVA PSYCHIATRIC SERVICES INC 1261 FURNACE BROOK PARKWAY
QUINCY MA
02169
US

IV. Provider business mailing address

NOVA PSYCHIATRIC SERVICES INC 1261 FURNACE BROOK PARKWAY
QUINCY MA
02169
US

V. Phone/Fax

Practice location:
  • Phone: 617-479-4545
  • Fax: 617-479-4555
Mailing address:
  • Phone: 617-479-4545
  • Fax: 617-479-4555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number5084
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number5084
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: