MEDICARE: FAMILY LEGACY MENTAL HEALTH SERVICES, INC

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	251B00000X	Case Management Agency
2	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1437499613
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY LEGACY MENTAL HEALTH SERVICES, INC

Provider Business Mailing Address
First Line	:	1011 SCHAUB DR
Second Line	:	SUITE 200
City	:	RALEIGH
State	:	NC
Zip	:	27606-1862
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1007 BROAD ST
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27705-4143
Country	:	US
Telephone Number	:	919-834-2000
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	LISA DYAN STACEY
Credential	:	B.S. Q.P.
Telephone Number	:	919-834-2000

Provider Enumeration Date	:	02/25/2013
Last Update Date	:	04/14/2014

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