MEDICARE: P & C LEGACY COUNSELING AND CONSULTATION, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1073110821
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	P & C LEGACY COUNSELING AND CONSULTATION, LLC

Provider Business Mailing Address
First Line	:	539 W COMMERCE ST # 1057
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75208-1953
Country	:	US
Telephone Number	:	469-951-3697
Fax Number	:

Provider Business Practice Location Address
First Line	:	539 W COMMERCE ST # 1057
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75208-1953
Country	:	US
Telephone Number	:	469-951-3697
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MS. SHICAGO PAGE
Credential	:	LPC
Telephone Number	:	469-951-3697

Provider Enumeration Date	:	10/05/2020
Last Update Date	:	10/05/2020

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