Healthcare Provider Details

I. General information

NPI: 1083008312
Provider Name (Legal Business Name): JUDYTH A. LEAVITT PSYCHOTHERAPIST P.L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2015
Last Update Date: 03/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 EMERALD ST STE C
KEENE NH
03431-3610
US

IV. Provider business mailing address

PO BOX 384
KEENE NH
03431-0384
US

V. Phone/Fax

Practice location:
  • Phone: 603-903-2122
  • Fax:
Mailing address:
  • Phone: 603-903-2122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1514
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0631
License Number StateNH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JUDYTH A LEAVITT
Title or Position: CEO
Credential:
Phone: 603-903-2122