MEDICARE: MRS. LEATHA JANELLE CARSON MA, NCC, LPC

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	68722	TX

General Provider Information

NPI Number	:	1699198739
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LEATHA JANELLE CARSON MA, NCC, LPC

Provider Business Mailing Address
First Line	:	1846 LOCKHILL SELMA RD
Second Line	:	#102
City	:	SAN ANTONIO
State	:	TX
Zip	:	78213-1570
Country	:	US
Telephone Number	:	210-316-7847
Fax Number	:

Provider Business Practice Location Address
First Line	:	1846 LOCKHILL SELMA RD
Second Line	:	#102
City	:	SAN ANTONIO
State	:	TX
Zip	:	78213-1570
Country	:	US
Telephone Number	:	210-316-7847
Fax Number	:

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

Provider Enumeration Date	:	01/24/2014
Last Update Date	:	01/24/2014

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