Provider Demographics
NPI:1730397191
Name:LEARY, MATTHEW S BURGESS (PHD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:S BURGESS
Last Name:LEARY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1923 J N PEASE PL
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-4513
Mailing Address - Country:US
Mailing Address - Phone:704-503-3535
Mailing Address - Fax:704-593-5555
Practice Address - Street 1:1923 J N PEASE PL
Practice Address - Street 2:SUITE 204
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-4513
Practice Address - Country:US
Practice Address - Phone:704-503-3535
Practice Address - Fax:704-593-5555
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC2200X, 103TF0000X
NC3953103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical