MEDICARE: LEAD 1 TEACH 1

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1316211626
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEAD 1 TEACH 1

Provider Business Mailing Address
First Line	:	201 BROCKMAN HGTS
Second Line	:
City	:	UNION
State	:	SC
Zip	:	29379
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	810 DIXON BLVD
Second Line	:
City	:	SHELBY
State	:	NC
Zip	:	28150
Country	:	US
Telephone Number	:	864-441-4948
Fax Number	:

Authorized Official
Title or Position	:	CO-OWNER
Name	:	LAKENDRA BRANNON
Credential	:
Telephone Number	:	864-266-8726

Provider Enumeration Date	:	03/05/2012
Last Update Date	:	03/05/2012

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Directions to “LEAD 1 TEACH 1 ” Practice Location

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