Provider Demographics
NPI:1558556035
Name:LEAHY, KERRY LYNN (PHD)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:LYNN
Last Name:LEAHY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KERRY
Other - Middle Name:LYNN
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:6369 ALMOND LN
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-2202
Mailing Address - Country:US
Mailing Address - Phone:248-212-8739
Mailing Address - Fax:
Practice Address - Street 1:6548 TOWN CENTER DR STE D
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-4823
Practice Address - Country:US
Practice Address - Phone:248-212-8739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-08
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013772103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical