MEDICARE: LEAH I JOHNSON

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	101YP2500X	Professional Counselor	LC13066	MD
2	101YM0800X	Mental Health Counselor	A15668	NC
3	390200000X	Student in an Organized Health Care Education/Training Program	LGP9979	MD

General Provider Information

NPI Number	:	1699309864
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEAH I JOHNSON

Provider Business Mailing Address
First Line	:	1476 PATRICK HENRY AVE
Second Line	:
City	:	CHARLOTTE COURT HOUSE
State	:	VA
Zip	:	23923-3733
Country	:	US
Telephone Number	:	443-820-6837
Fax Number	:

Provider Business Practice Location Address
First Line	:	1476 PATRICK HENRY AVE
Second Line	:
City	:	CHARLOTTE COURT HOUSE
State	:	VA
Zip	:	23923-3733
Country	:	US
Telephone Number	:	443-820-6837
Fax Number	:

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

Provider Enumeration Date	:	02/26/2020
Last Update Date	:	09/13/2022

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