Provider Demographics
NPI:1770180838
Name:LEGACY FAMILY SERVICES, LLC
Entity Type:Organization
Organization Name:LEGACY FAMILY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:T
Authorized Official - Last Name:DUDLEY HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:202-746-4345
Mailing Address - Street 1:11415 OLD POND DR
Mailing Address - Street 2:
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-9154
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11415 OLD POND DR
Practice Address - Street 2:
Practice Address - City:GLENN DALE
Practice Address - State:MD
Practice Address - Zip Code:20769-9154
Practice Address - Country:US
Practice Address - Phone:301-200-2919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
EM58-0000OtherCAREFIRST