Provider Demographics
NPI:1679078133
Name:LEGACY OF JOSH ACADEMY
Entity Type:Organization
Organization Name:LEGACY OF JOSH ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SOLFINE
Authorized Official - Middle Name:
Authorized Official - Last Name:DORLEUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-703-4381
Mailing Address - Street 1:449 W SILVER STAR RD UNIT 313
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-8013
Mailing Address - Country:US
Mailing Address - Phone:321-914-9949
Mailing Address - Fax:
Practice Address - Street 1:380 SEMORAN COMMERCE PL STE 209
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-4684
Practice Address - Country:US
Practice Address - Phone:407-703-4381
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-27
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No251E00000XAgenciesHome HealthGroup - Single Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========Medicaid