Provider Demographics
NPI:1346267820
Name:LEGACY PSYCHOLOGICAL SERVICES, LLC
Entity Type:Organization
Organization Name:LEGACY PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:A
Authorized Official - Last Name:GABIS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:513-699-9240
Mailing Address - Street 1:PO BOX 634927
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0042
Mailing Address - Country:US
Mailing Address - Phone:513-891-2813
Mailing Address - Fax:513-793-1032
Practice Address - Street 1:7105 HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45231-5218
Practice Address - Country:US
Practice Address - Phone:513-699-9240
Practice Address - Fax:513-681-8959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2922476Medicaid
DE6598OtherRR MEDICARE
OH9357721Medicare PIN