Provider Demographics
NPI:1609981430
Name:LEGG, LARRY THEODORE II (LCSW)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:THEODORE
Last Name:LEGG
Suffix:II
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 LATELIA CT
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-4907
Mailing Address - Country:US
Mailing Address - Phone:813-965-2800
Mailing Address - Fax:813-933-4265
Practice Address - Street 1:8019 N HIMES AVE
Practice Address - Street 2:SUITE 311
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-2712
Practice Address - Country:US
Practice Address - Phone:813-965-2800
Practice Address - Fax:813-933-4265
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2008-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 56851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ063YZMedicare ID - Type Unspecified