MEDICARE: MRS. CAROL VANESSA LEIVA LCPC

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	PRC200001560	DC
2	101YP2500X	Professional Counselor	0701010913	VA
3	101YP2500X	Professional Counselor	LC7303	MD

General Provider Information

NPI Number	:	1780013540
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CAROL VANESSA LEIVA LCPC

Provider Business Mailing Address
First Line	:	12212 ATHERTON DR
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20902-1006
Country	:	US
Telephone Number	:	202-316-6937
Fax Number	:

Provider Business Practice Location Address
First Line	:	12212 ATHERTON DR
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20902-1006
Country	:	US
Telephone Number	:	202-316-6937
Fax Number	:

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

Provider Enumeration Date	:	11/02/2013
Last Update Date	:	06/05/2023

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