Provider Demographics
NPI:1003694753
Name:LEGENDRE, TEGAN JEAN (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:TEGAN
Middle Name:JEAN
Last Name:LEGENDRE
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3257 LOWER BURRIS RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-4495
Mailing Address - Country:US
Mailing Address - Phone:470-334-3324
Mailing Address - Fax:
Practice Address - Street 1:3257 LOWER BURRIS RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-4495
Practice Address - Country:US
Practice Address - Phone:470-334-3324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-14
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-23-67794103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst