Provider Demographics
NPI:1912579202
Name:LEGACY WELLNESS SERVICES LLC
Entity Type:Organization
Organization Name:LEGACY WELLNESS SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LICSW
Authorized Official - Phone:228-231-0516
Mailing Address - Street 1:6068 US HWY 98 WEST
Mailing Address - Street 2:STE 1 BOX 304
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402
Mailing Address - Country:US
Mailing Address - Phone:228-231-0516
Mailing Address - Fax:
Practice Address - Street 1:6068 US HWY 98 WEST
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402
Practice Address - Country:US
Practice Address - Phone:228-231-0516
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherBLUE CROSS BLUE SHIELD