Provider Demographics
NPI:1386734572
Name:LEAHY, JOHN J (EDD)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:J
Last Name:LEAHY
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NOVA PSYCHIATRIC SERVICES INC
Mailing Address - Street 2:1261 FURNACE BROOK PARKWAY
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169
Mailing Address - Country:US
Mailing Address - Phone:617-479-4545
Mailing Address - Fax:617-479-4555
Practice Address - Street 1:NOVA PSYCHIATRIC SERVICES INC
Practice Address - Street 2:1261 FURNACE BROOK PARKWAY
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169
Practice Address - Country:US
Practice Address - Phone:617-479-4545
Practice Address - Fax:617-479-4555
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5084103TH0100X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6100041OtherEVERCARE PROVIDER NUMBER
MA1891227Medicaid
MAW04815OtherBCBS PROVIDER NUMBER
MA1891227Medicaid