MEDICARE: MR. SAMUEL LEE JOHNSON III CAC, CCGC

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	251S00000X	Community/Behavioral Health Agency
2	343900000X	Non-emergency Medical Transport (VAN)	010494439	LA
3	171000000X	Military Health Care Provider
4	171M00000X	Case Manager/Care Coordinator
5	175T00000X	Peer Specialist
6	225C00000X	Rehabilitation Counselor
7	101Y00000X	Counselor
8	101YA0400X	Addiction (Substance Use Disorder) Counselor
9	101YM0800X	Mental Health Counselor
10	101YP1600X	Pastoral Counselor
11	103TA0400X	Addiction (Substance Use Disorder) Psychologist
12	103TC1900X	Counseling Psychologist
13	101YP2500X	Professional Counselor	5006	LA
14	101YA0400X	Addiction (Substance Use Disorder) Counselor	1603	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	461582868	OTHER	LA	461582868

General Provider Information

NPI Number	:	1184095556
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SAMUEL LEE JOHNSON III CAC, CCGC

Provider Business Mailing Address
First Line	:	PO BOX 2637
Second Line	:
City	:	HARVEY
State	:	LA
Zip	:	70059-2637
Country	:	US
Telephone Number	:	504-261-4976
Fax Number	:	504-766-6792

Provider Business Practice Location Address
First Line	:	2439 MANHATTAN BLVD STE 102-4
Second Line	:
City	:	HARVEY
State	:	LA
Zip	:	70058-5473
Country	:	US
Telephone Number	:	504-261-4976
Fax Number	:	504-766-8457

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

Provider Enumeration Date	:	10/12/2015
Last Update Date	:	01/12/2021

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