MEDICARE: MR. JOHNNY LEE COUNTS LCDC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	9491	TX

General Provider Information

NPI Number	:	1861671562
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHNNY LEE COUNTS LCDC

Provider Business Mailing Address
First Line	:	2815 RICHMOND RD
Second Line	:	#122
City	:	TEXARKANA
State	:	TX
Zip	:	75503-5100
Country	:	US
Telephone Number	:	903-334-9067
Fax Number	:	903-334-9067

Provider Business Practice Location Address
First Line	:	2815 RICHMOND RD
Second Line	:	#122
City	:	TEXARKANA
State	:	TX
Zip	:	75503-5100
Country	:	US
Telephone Number	:	903-334-9067
Fax Number	:	903-334-9067

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

Provider Enumeration Date	:	10/30/2007
Last Update Date	:	10/30/2007

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