Provider Demographics
NPI:1326690314
Name:LEGACY LIFE COUNSELING & CONSULTING SERVICES, PLC
Entity Type:Organization
Organization Name:LEGACY LIFE COUNSELING & CONSULTING SERVICES, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PROGRAM DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LA TOSHA
Authorized Official - Middle Name:A
Authorized Official - Last Name:LYMON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:248-270-7092
Mailing Address - Street 1:17360 W 12 MILE RD STE 104
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2117
Mailing Address - Country:US
Mailing Address - Phone:248-270-7092
Mailing Address - Fax:
Practice Address - Street 1:31268 SHORECREST DR APT 24302
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-1182
Practice Address - Country:US
Practice Address - Phone:248-270-7092
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No347D00000XTransportation ServicesTrainGroup - Multi-Specialty