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General NPI Number Information
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NPI Number | 1316585508
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Entity Type | Organization
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Legal Business Name | JUSTIN LEAHY CRNP-PMH LL
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Dates
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Enumeration Date | 12/18/2019
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Last Update Date | 12/18/2019
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Provider Practice Location Address
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Address Line | 4353 ENSBROOK LN
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City | WOODBRIDGE
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State | VA
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Zip | 22193-2652
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Country | US
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Telephone | 410-562-2867
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Fax |
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Provider Business Mailing Address
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Address Line | 1812 E REGENTS PARK RD
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City | CROFTON
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State | MD
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Zip | 21114-2528
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Country | US
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Telephone | 410-562-2867
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. JUSTIN P LEAHY
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Credential | CRNP-PMH
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Telephone | 410-562-2867
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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