Provider Demographics
NPI:1861837288
Name:LEGENDARY THERAPY
Entity Type:Organization
Organization Name:LEGENDARY THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SALOMON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, OTR/L
Authorized Official - Phone:917-853-1226
Mailing Address - Street 1:997 STAFFORD AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-2109
Mailing Address - Country:US
Mailing Address - Phone:917-853-1226
Mailing Address - Fax:718-679-9823
Practice Address - Street 1:997 STAFFORD AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309-2109
Practice Address - Country:US
Practice Address - Phone:917-853-1226
Practice Address - Fax:718-679-9823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-30
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency