Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101Y00000X | Counselor | ||
N | 101YA0400X | Addiction Counselor (Substance Use Disorder) | ||
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 1603 | LA |
N | 101YM0800X | Mental Health Counselor | ||
N | 101YP1600X | Pastoral Counselor | ||
N | 101YP2500X | Professional Counselor | 5006 | LA |
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | ||
N | 103TC1900X | Counseling Psychologist | ||
N | 225C00000X | Rehabilitation Counselor |
NPI | 1184095556 |
---|---|
Provider Name | Mr. Samuel Lee Johnson III |
First Address | Harvey, LA 70059-2637 |
Second Address | Harvey, LA 70058-5473 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/10/2015 |
Last Update Date | 12/01/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
461582868 | 461582868 (01) | LA |