MEDICARE: MR. LEON DANGERFIELD R-CPRS

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	175T00000X	Peer Specialist	0735000361	VA

General Provider Information

NPI Number	:	1396435020
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LEON DANGERFIELD R-CPRS

Provider Business Mailing Address
First Line	:	108 MEADOWSPRING RD
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23223-5640
Country	:	US
Telephone Number	:	804-499-9677
Fax Number	:

Provider Business Practice Location Address
First Line	:	108 MEADOWSPRING RD
Second Line	:
City	:	HENRICO
State	:	VA
Zip	:	23223
Country	:	US
Telephone Number	:	804-499-9677
Fax Number	:

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

Provider Enumeration Date	:	05/08/2023
Last Update Date	:	05/08/2023

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