Provider Demographics
NPI:1629234422
Name:LEGACY BEHAVIORAL HEALTH CENTER
Entity Type:Organization
Organization Name:LEGACY BEHAVIORAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHABIORAL TECHNICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:ADORNO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-873-6640
Mailing Address - Street 1:643 SE CHAPMAN AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34984-4502
Mailing Address - Country:US
Mailing Address - Phone:772-873-6640
Mailing Address - Fax:
Practice Address - Street 1:643 SE CHAPMAN AVE.
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34984
Practice Address - Country:US
Practice Address - Phone:772-873-6640
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health