MEDICARE: LEAH RIDDELL

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	LCAS25975	NC
2	101YM0800X	Mental Health Counselor	LCMHCA15523	NC

General Provider Information

NPI Number	:	1811537202
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEAH RIDDELL

Provider Business Mailing Address
First Line	:	704 CROMWELL DR STE A
Second Line	:
City	:	GREENVILLE
State	:	NC
Zip	:	27858-5894
Country	:	US
Telephone Number	:	252-220-5896
Fax Number	:

Provider Business Practice Location Address
First Line	:	704 CROMWELL DR STE A
Second Line	:
City	:	GREENVILLE
State	:	NC
Zip	:	27858-5894
Country	:	US
Telephone Number	:	252-220-5896
Fax Number	:

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

Provider Enumeration Date	:	01/14/2020
Last Update Date	:	07/18/2022

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704 CROMWELL DR STE B
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1457580847 — MR. EDWARD ANGUS JOHNSTON M.S., LPC, LCAS
Practice Location Address:

704 CROMWELL DR , SUITE B
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Directions to “ LEAH RIDDELL ” Practice Location

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