Provider Demographics
NPI:1003067380
Name:LEGG, VANESSA ANN (MSW)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:ANN
Last Name:LEGG
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2611 SOLANO AVE
Mailing Address - Street 2:APT 301
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-3723
Mailing Address - Country:US
Mailing Address - Phone:256-740-1205
Mailing Address - Fax:
Practice Address - Street 1:1401 S FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2619
Practice Address - Country:US
Practice Address - Phone:954-712-5079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-06
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012803100Medicaid