Provider Demographics
NPI:1770510075
Name:LEGACY COUNSELING CENTER INC
Entity Type:Organization
Organization Name:LEGACY COUNSELING CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:GROVE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, MS
Authorized Official - Phone:214-520-6308
Mailing Address - Street 1:4054 MCKINNEY AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-2050
Mailing Address - Country:US
Mailing Address - Phone:214-520-6308
Mailing Address - Fax:
Practice Address - Street 1:4054 MCKINNEY AVE STE 102
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-2050
Practice Address - Country:US
Practice Address - Phone:214-520-6308
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS188031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
55GTOtherBCBS
TX079683102Medicaid
TX079683102Medicaid