Basic Information
| Provider Information | |||||||||
| NPI: | 1215107099 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEARY | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 113 ELM ST STE 204 | ||||||||
| Address2: | |||||||||
| City: | ENFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060823739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607413001 | ||||||||
| FaxNumber: | 8607418332 | ||||||||
| Practice Location | |||||||||
| Address1: | 113 ELM ST STE 204 | ||||||||
| Address2: | |||||||||
| City: | ENFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060823739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607413001 | ||||||||
| FaxNumber: | 8607418332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2008 | ||||||||
| LastUpdateDate: | 03/07/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 000476 | CT | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 000061 | CT | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | 3665 | MA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 000061 | CT | N | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 301508 | 01 | CT | MANAGED HEALTH NETWORK | OTHER | A412956 | 01 | CT | OXFORD INSURANCE | OTHER | CTGA000477-B001475 | 01 | CT | STATE ADMINISTER ASST. | OTHER | 321137 | 01 | CT | VALUE OPTIONS | OTHER | 300000476CT01 | 01 | CT | ANTHEM BC/BS | OTHER |