Provider Demographics
NPI: | 1952877219 |
---|---|
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: | 4432 PARK HEIGHTS AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | BALTIMORE |
Mailing Address - State: | MD |
Mailing Address - Zip Code: | 21215-6315 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 410-728-4491 |
Mailing Address - Fax: | 410-728-5729 |
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?: | Yes |
Parent Organization LBN: | LEGACY TREATMENT LLC |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2018-10-15 |
Last Update Date: | 2018-10-15 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Single Specialty |