Provider Demographics
NPI:1003201062
Name:LEGENDARY THERAPY
Entity Type:Organization
Organization Name:LEGENDARY THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SERVICE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:YOLIVETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-610-9454
Mailing Address - Street 1:660 SOUTHERN BLVD
Mailing Address - Street 2:5D
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10455-3653
Mailing Address - Country:US
Mailing Address - Phone:718-610-9454
Mailing Address - Fax:
Practice Address - Street 1:1925 WILLIAMSBRIDGE RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-1604
Practice Address - Country:US
Practice Address - Phone:718-941-1900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency