Provider Demographics
NPI:1609519701
Name:IM LEGACY COUNSELING & CONSULTATION SERVICES, LLC
Entity Type:Organization
Organization Name:IM LEGACY COUNSELING & CONSULTATION SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-FOUNDER
Authorized Official - Prefix:MISS
Authorized Official - First Name:VAYA
Authorized Official - Middle Name:MILAN
Authorized Official - Last Name:FRALEY
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:614-706-1899
Mailing Address - Street 1:3737 EASTON MARKET UNIT 1201
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219-6023
Mailing Address - Country:US
Mailing Address - Phone:614-706-1899
Mailing Address - Fax:
Practice Address - Street 1:3562 PIEDMONT RD NE APT 305
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-7003
Practice Address - Country:US
Practice Address - Phone:614-206-4452
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-16
Last Update Date:2022-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty