Provider Demographics
NPI:1316585508
Name:JUSTIN LEAHY CRNP-PMH LL
Entity Type:Organization
Organization Name:JUSTIN LEAHY CRNP-PMH LL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:P
Authorized Official - Last Name:LEAHY
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP-PMH
Authorized Official - Phone:410-562-2867
Mailing Address - Street 1:1812 E REGENTS PARK RD
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-2528
Mailing Address - Country:US
Mailing Address - Phone:410-562-2867
Mailing Address - Fax:
Practice Address - Street 1:4353 ENSBROOK LN
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193-2652
Practice Address - Country:US
Practice Address - Phone:410-562-2867
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-18
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty