Provider Demographics
NPI:1932371655
Name:FAMILY LEGACY MENTAL HEALTH SERVICES INC
Entity Type:Organization
Organization Name:FAMILY LEGACY MENTAL HEALTH SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:DYAN
Authorized Official - Last Name:STACEY
Authorized Official - Suffix:
Authorized Official - Credentials:BS QP
Authorized Official - Phone:919-834-2000
Mailing Address - Street 1:1011 SCHAUB DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27606-1862
Mailing Address - Country:US
Mailing Address - Phone:919-834-2000
Mailing Address - Fax:919-834-2001
Practice Address - Street 1:1007 BROAD ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-4143
Practice Address - Country:US
Practice Address - Phone:919-834-2000
Practice Address - Fax:919-834-2001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6102775101YP2500X
NC6107485103TC0700X
NC6001168103TC1900X
NC6105171106H00000X
NC93005962080A0000X
251B00000X, 251S00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8302925Medicaid
NC8302411Medicaid
NC5913953Medicaid
NC6006506Medicaid