MEDICARE: MS. TOMEIKA SHONDALE LEAVELL LCSW

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	252888	KY

General Provider Information

NPI Number	:	1417509522
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TOMEIKA SHONDALE LEAVELL LCSW

Provider Business Mailing Address
First Line	:	4509 LOUANE WAY
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40216-2711
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4509 LOUANE WAY
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40216-2711
Country	:	US
Telephone Number	:	757-362-2421
Fax Number	:

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

Provider Enumeration Date	:	07/10/2019
Last Update Date	:	07/10/2019

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