Provider Demographics
NPI:1780261628
Name:LEAHY, CODY
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:LEAHY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9845 MIRA LEE WAY APT 30307
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-6760
Mailing Address - Country:US
Mailing Address - Phone:757-268-8980
Mailing Address - Fax:
Practice Address - Street 1:9845 MIRA LEE WAY APT 30307
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-6760
Practice Address - Country:US
Practice Address - Phone:757-268-8980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-26
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program