Provider Demographics
NPI:1578183570
Name:LEAHY, HILARY ANN
Entity Type:Individual
Prefix:
First Name:HILARY
Middle Name:ANN
Last Name:LEAHY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 SENOIA RD
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:GA
Mailing Address - Zip Code:30290-1625
Mailing Address - Country:US
Mailing Address - Phone:770-626-3044
Mailing Address - Fax:
Practice Address - Street 1:1135 SENOIA RD
Practice Address - Street 2:
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290-1625
Practice Address - Country:US
Practice Address - Phone:770-626-3044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-20
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-21-78690103K00000X
GA1-21-50336103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003218736AMedicaid