Provider Demographics
NPI:1417665480
Name:LEGACY COUNSELING, LLC
Entity Type:Organization
Organization Name:LEGACY COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ROSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LABRIOLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-213-4930
Mailing Address - Street 1:165 CAMBRIDGEPARK DR UNIT 217
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02140-2486
Mailing Address - Country:US
Mailing Address - Phone:857-392-2234
Mailing Address - Fax:
Practice Address - Street 1:125 CAMBRIDGEPARK DR STE 301
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02140-2392
Practice Address - Country:US
Practice Address - Phone:857-392-2234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA11304OtherSTATE OF MASSACHUSETTS LICENSE