Provider Demographics
NPI:1861752990
Name:PERNICIARO - BLAIR, LEAH ANN (PSYD)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:ANN
Last Name:PERNICIARO - BLAIR
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 BOWDOIN STREET
Mailing Address - Street 2:SUITE 1 A/B
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13 BOWDOIN STREET
Practice Address - Street 2:SUITE 1 A/B
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:508-852-1805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-23
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MA10213103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health