Basic Information
| Provider Information | |||||||||
| NPI: | 1386734572 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEAHY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | EDD | ||||||||
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| Mailing Information | |||||||||
| Address1: | NOVA PSYCHIATRIC SERVICES INC | ||||||||
| Address2: | 1261 FURNACE BROOK PARKWAY | ||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174794545 | ||||||||
| FaxNumber: | 6174794555 | ||||||||
| Practice Location | |||||||||
| Address1: | NOVA PSYCHIATRIC SERVICES INC | ||||||||
| Address2: | 1261 FURNACE BROOK PARKWAY | ||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174794545 | ||||||||
| FaxNumber: | 6174794555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 02/26/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TH0100X | 5084 | MA | N | Behavioral Health & Social Service Providers | Psychologist | Health Service | 103TC0700X | 5084 | MA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6100041 | 01 | MA | EVERCARE PROVIDER NUMBER | OTHER | 1891227 | 05 | MA | MEDICAID | W04815 | 01 | MA | BCBS PROVIDER NUMBER | OTHER |