Provider Demographics
NPI:1225189699
Name:LEADER, JODY (PHD)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:LEADER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 HARVARD ST
Mailing Address - Street 2:#8B
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-6478
Mailing Address - Country:US
Mailing Address - Phone:617-734-8868
Mailing Address - Fax:
Practice Address - Street 1:124 HARVARD ST
Practice Address - Street 2:#8B
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-6478
Practice Address - Country:US
Practice Address - Phone:617-734-8868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8001103TC0700X, 103TF0000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MALE W51223Medicare ID - Type UnspecifiedMEDICARE B PROGRAM