Basic Information
| Provider Information | |||||||||
| NPI: | 1336423276 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEARY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | RICHARD | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | CSAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 44-174 LAHA ST | ||||||||
| Address2: | APT.1 | ||||||||
| City: | KANEOHE | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967442636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8082757805 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 277 OHUA AVE | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968156612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8089224787 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2011 | ||||||||
| LastUpdateDate: | 10/10/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1612-11 | HI | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.