MEDICARE: BRIAN LEGG

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	103T00000X	Psychologist	017910	PA
2	103T00000X	Psychologist	35SI00557600	NJ

General Provider Information

NPI Number	:	1114399383
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN LEGG

Provider Business Mailing Address
First Line	:	125 RIVER RD STE 106
Second Line	:
City	:	EDGEWATER
State	:	NJ
Zip	:	07020-1002
Country	:	US
Telephone Number	:	201-606-2592
Fax Number	:

Provider Business Practice Location Address
First Line	:	125 RIVER RD STE 106
Second Line	:
City	:	EDGEWATER
State	:	NJ
Zip	:	07020-1002
Country	:	US
Telephone Number	:	201-606-2592
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/27/2015
Last Update Date	:	12/03/2024

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Directions to “ BRIAN LEGG ” Practice Location

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