Basic Information
| Provider Information | |||||||||
| NPI: | 1407132079 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEONARD | ||||||||
| FirstName: | JOHNNY | ||||||||
| MiddleName: | D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 904 NORWOOD ST | ||||||||
| Address2: | APT 5 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283054896 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104890429 | ||||||||
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| Practice Location | |||||||||
| Address1: | 901 ARSENAL AVE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283055398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103233368 | ||||||||
| FaxNumber: | 9104867000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2011 | ||||||||
| LastUpdateDate: | 10/10/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 9092 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101YA0400X | 2305 | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 6112397 | 05 | NC | MEDICAID |