Provider Demographics
NPI:1114519360
Name:LEGEND PSYCH LLC
Entity Type:Organization
Organization Name:LEGEND PSYCH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:W
Authorized Official - Last Name:JONAS
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:201-523-4113
Mailing Address - Street 1:239 PROSPECT AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:NEW MILFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07646-1764
Mailing Address - Country:US
Mailing Address - Phone:201-523-4113
Mailing Address - Fax:
Practice Address - Street 1:550 KINDERKAMACK RD STE 108
Practice Address - Street 2:
Practice Address - City:ORADELL
Practice Address - State:NJ
Practice Address - Zip Code:07649-1500
Practice Address - Country:US
Practice Address - Phone:201-523-4113
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-09
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health