Provider Demographics
NPI:1437505757
Name:LEGACY COUNSELING LLC
Entity Type:Organization
Organization Name:LEGACY COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MALA
Authorized Official - Middle Name:DEVI
Authorized Official - Last Name:DEODHARI-BENI
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:732-991-1556
Mailing Address - Street 1:#1045 555 HIGH STREET
Mailing Address - Street 2:STE 9
Mailing Address - City:MOUNT HOLLY
Mailing Address - State:NJ
Mailing Address - Zip Code:08060-1062
Mailing Address - Country:US
Mailing Address - Phone:732-991-1556
Mailing Address - Fax:
Practice Address - Street 1:1520 NORTHUMBERLAND WAY
Practice Address - Street 2:
Practice Address - City:MONMOUTH JUNCTION
Practice Address - State:NJ
Practice Address - Zip Code:08852-2374
Practice Address - Country:US
Practice Address - Phone:732-991-1556
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-05
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC05563800101YM0800X, 251S00000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ87-2066325Medicaid