Provider Demographics
NPI:1336770627
Name:LEGACY'S IMPACT INTERVENTION L.L.C
Entity Type:Organization
Organization Name:LEGACY'S IMPACT INTERVENTION L.L.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SHONTA
Authorized Official - Middle Name:
Authorized Official - Last Name:CROWDER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:918-766-6998
Mailing Address - Street 1:3606 IDAHO AVE
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006-2420
Mailing Address - Country:US
Mailing Address - Phone:918-766-6998
Mailing Address - Fax:
Practice Address - Street 1:3606 IDAHO AVE
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-2420
Practice Address - Country:US
Practice Address - Phone:918-766-6998
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty