Provider Demographics
NPI:1205377678
Name:LEGACY COUNSELING SERVICE
Entity Type:Organization
Organization Name:LEGACY COUNSELING SERVICE
Other - Org Name:MELISSA LEEDY, PH.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPERTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:LEEDY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:918-505-4367
Mailing Address - Street 1:6406 E FORT WORTH PL
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-7043
Mailing Address - Country:US
Mailing Address - Phone:918-505-4367
Mailing Address - Fax:888-371-9410
Practice Address - Street 1:2035A WEST HOUSTON STREET
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-8792
Practice Address - Country:US
Practice Address - Phone:918-505-4367
Practice Address - Fax:888-371-9410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-17
Last Update Date:2022-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1268103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty