Provider Demographics
NPI:1407374986
Name:LEGAGNEUR, MARY ALIXANDRIA
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALIXANDRIA
Last Name:LEGAGNEUR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1163 PRESIDENT ST APT 7
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-1749
Mailing Address - Country:US
Mailing Address - Phone:347-254-3425
Mailing Address - Fax:
Practice Address - Street 1:2316 SURF AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224-2113
Practice Address - Country:US
Practice Address - Phone:718-946-1919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-05
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health