Provider Demographics
NPI:1437681038
Name:LEGION THERAPEUTIC GROUP, LLC
Entity Type:Organization
Organization Name:LEGION THERAPEUTIC GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:267-595-0588
Mailing Address - Street 1:3553 W CHESTER PIKE UNIT 320
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19073-3701
Mailing Address - Country:US
Mailing Address - Phone:844-534-4661
Mailing Address - Fax:888-226-4103
Practice Address - Street 1:14 ELLIOTT AVE
Practice Address - Street 2:SUITE 9
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-3412
Practice Address - Country:US
Practice Address - Phone:844-534-4661
Practice Address - Fax:888-226-4103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-02
Last Update Date:2017-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC008692101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty