=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356030951
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEAF AND STONE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2023
-----------------------------------------------------
Last Update Date | 04/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2919 E BROADWAY BLVD # 205
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85716-5301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-654-5502
-----------------------------------------------------
Fax | 520-842-8765
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3814 E 5TH ST
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85716-5145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-372-8575
-----------------------------------------------------
Fax | 520-372-8576
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PROVIDER
-----------------------------------------------------
Name | JOHANNAH BLAKE
-----------------------------------------------------
Credential | PMHNP-BC
-----------------------------------------------------
Telephone | 520-654-5502
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------