Provider Demographics
NPI:1003086265
Name:LEAHY, TIMOTHY WILLIAM (LICSW)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:WILLIAM
Last Name:LEAHY
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:284 BACON ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-7521
Mailing Address - Country:US
Mailing Address - Phone:781-642-9601
Mailing Address - Fax:
Practice Address - Street 1:284 BACON ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-7521
Practice Address - Country:US
Practice Address - Phone:781-642-9601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-04
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10249261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical