Provider Demographics
NPI:1790117877
Name:LEGG, AMANDA JEANNE (MS, ADC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEANNE
Last Name:LEGG
Suffix:
Gender:F
Credentials:MS, ADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3250 SWEETWATER RD APT 1605
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-6519
Mailing Address - Country:US
Mailing Address - Phone:423-794-6525
Mailing Address - Fax:
Practice Address - Street 1:3390 N BERKELEY LAKE RD NW STE 100
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-3006
Practice Address - Country:US
Practice Address - Phone:470-704-5050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-31
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
CACATC-I #3025101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)