MEDICARE: LACONYA CHARMAINE WITHERSPOON

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	385H00000X	Respite Care

General Provider Information

NPI Number	:	1023984846
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACONYA CHARMAINE WITHERSPOON

Provider Business Mailing Address
First Line	:	1213 E 173RD ST APT 1
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44119-3168
Country	:	US
Telephone Number	:	216-250-5685
Fax Number	:

Provider Business Practice Location Address
First Line	:	1213 E 173RD ST APT 1
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44119-3168
Country	:	US
Telephone Number	:	216-250-5685
Fax Number	:

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

Provider Enumeration Date	:	10/17/2025
Last Update Date	:	05/21/2026

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Directions to “ LACONYA CHARMAINE WITHERSPOON ” Practice Location

Language	Start Address	Practice Location

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