Provider Demographics
NPI:1609765742
Name:LEGACY WELLNESS MENTAL HEALTH SERVICES LLC
Entity type:Organization
Organization Name:LEGACY WELLNESS MENTAL HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIESHARA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MATTHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:757-724-0351
Mailing Address - Street 1:1385 FORDHAM DR STE 105-138
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-5345
Mailing Address - Country:US
Mailing Address - Phone:757-563-3378
Mailing Address - Fax:
Practice Address - Street 1:1385 FORDHAM DR STE 105-138
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-5345
Practice Address - Country:US
Practice Address - Phone:757-724-0351
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-02
Last Update Date:2025-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty