Provider Demographics
NPI:1912472473
Name:LEGACY TREATMENT LLC
Entity Type:Organization
Organization Name:LEGACY TREATMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:LLOYD
Authorized Official - Middle Name:A
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-558-8514
Mailing Address - Street 1:826 HOLLINS ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1004
Mailing Address - Country:US
Mailing Address - Phone:973-558-8514
Mailing Address - Fax:
Practice Address - Street 1:4432 PARK HEIGHTS AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-6315
Practice Address - Country:US
Practice Address - Phone:410-728-4491
Practice Address - Fax:410-728-5729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty