Provider Demographics
NPI:1790262780
Name:LEGAN, MACY (MCD)
Entity Type:Individual
Prefix:
First Name:MACY
Middle Name:
Last Name:LEGAN
Suffix:
Gender:F
Credentials:MCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6157 AIRPORT BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-3147
Mailing Address - Country:US
Mailing Address - Phone:251-287-0378
Mailing Address - Fax:251-287-0466
Practice Address - Street 1:4405 AIRLINE DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2058
Practice Address - Country:US
Practice Address - Phone:318-747-5440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2020-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1963235Z00000X
WYSP-1058235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist