Provider Demographics
NPI:1659934636
Name:LEGACY PSYCHOLOGICAL SERVICES
Entity Type:Organization
Organization Name:LEGACY PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:EVA
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:725-500-9035
Mailing Address - Street 1:3651 LINDELL RD # D396
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-1254
Mailing Address - Country:US
Mailing Address - Phone:725-500-9035
Mailing Address - Fax:702-929-3618
Practice Address - Street 1:3651 LINDELL RD # D396
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-1254
Practice Address - Country:US
Practice Address - Phone:725-500-9035
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-16
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1982755799Medicaid