Provider Demographics
NPI:1407132079
Name:LEONARD, JOHNNY D
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:D
Last Name:LEONARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 NORWOOD ST
Mailing Address - Street 2:APT 5
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305-4896
Mailing Address - Country:US
Mailing Address - Phone:910-489-0429
Mailing Address - Fax:
Practice Address - Street 1:901 ARSENAL AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5398
Practice Address - Country:US
Practice Address - Phone:910-323-3368
Practice Address - Fax:910-486-7000
Is Sole Proprietor?:No
Enumeration Date:2011-10-27
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9092101YP2500X
NC2305101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6112397Medicaid