Healthcare Provider Details

I. General information

NPI: 1962771329
Provider Name (Legal Business Name): THE LEGACY INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2011
Last Update Date: 12/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8190 W DEER VALLEY RD #297
PEORIA AZ
85382-2126
US

IV. Provider business mailing address

8190 W DEER VALLEY RD #297
PEORIA AZ
85382-2126
US

V. Phone/Fax

Practice location:
  • Phone: 623-398-4814
  • Fax: 623-234-3751
Mailing address:
  • Phone: 623-398-4814
  • Fax: 623-234-3751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number3984
License Number StateAZ

VIII. Authorized Official

Name: DR. SHARON BELL BANKS
Title or Position: MEMBER
Credential: PSYD
Phone: 623-398-4814