MEDICARE: LISHI LEO HUANG SUPPORT SPECIALIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	1910559	CA

General Provider Information

NPI Number	:	1821464462
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISHI LEO HUANG SUPPORT SPECIALIST

Provider Business Mailing Address
First Line	:	2116 S CENTRAL AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90011-1237
Country	:	US
Telephone Number	:	213-493-4664
Fax Number	:

Provider Business Practice Location Address
First Line	:	2116 S CENTRAL AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90011-1237
Country	:	US
Telephone Number	:	213-493-4664
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/18/2015
Last Update Date	:	03/26/2021

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