Provider Demographics
NPI:1568439685
Name:LEGACY BEHAVIORAL HEALTH CENTER INC
Entity Type:Organization
Organization Name:LEGACY BEHAVIORAL HEALTH CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:B
Authorized Official - Last Name:PAJARES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:561-722-7866
Mailing Address - Street 1:PO BOX 458
Mailing Address - Street 2:
Mailing Address - City:INDIANTOWN
Mailing Address - State:FL
Mailing Address - Zip Code:34956-0458
Mailing Address - Country:US
Mailing Address - Phone:772-597-0411
Mailing Address - Fax:772-597-0412
Practice Address - Street 1:15818 SW WARFIELD BLVD
Practice Address - Street 2:
Practice Address - City:INDIANTOWN
Practice Address - State:FL
Practice Address - Zip Code:34956-3513
Practice Address - Country:US
Practice Address - Phone:772-597-0411
Practice Address - Fax:772-597-0412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-07
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW52711041C0700X
FL6427251S00000X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL600058153OtherMAGELLAN HMO
FL076140100Medicaid
FLBP385 A-BMedicare PIN