MEDICARE: LEANNA RAE TALIAFERRO

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	113768	TX

General Provider Information

NPI Number	:	1841023520
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEANNA RAE TALIAFERRO

Provider Business Mailing Address
First Line	:	6817 JOHN MARSHALL ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78240-2925
Country	:	US
Telephone Number	:	210-557-0510
Fax Number	:

Provider Business Practice Location Address
First Line	:	4204 GARDENDALE ST STE 107
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-3138
Country	:	US
Telephone Number	:	210-334-0108
Fax Number	:

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

Provider Enumeration Date	:	08/20/2024
Last Update Date	:	08/20/2024

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