MEDICARE: DR. LETE MEKONEN ANSERA D.MIN, LCADC, MFT

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	0871	KY
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	167084	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821205865
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LETE MEKONEN ANSERA D.MIN, LCADC, MFT

Provider Business Mailing Address
First Line	:	4602 SOUTHERN PKWY STE 2C
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40214-1442
Country	:	US
Telephone Number	:	502-777-0213
Fax Number	:	855-894-9366

Provider Business Practice Location Address
First Line	:	4602 SOUTHERN PKWY STE 2C
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40214-1442
Country	:	US
Telephone Number	:	502-777-0213
Fax Number	:	855-894-9366

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

Provider Enumeration Date	:	05/17/2007
Last Update Date	:	08/18/2021

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