Healthcare Provider Details

I. General information

NPI: 1083542740
Provider Name (Legal Business Name): LEGACY BEHAVIORAL COLLECTIVE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 REDWOOD DRIVE
LA HONDA CA
94020-0332
US

IV. Provider business mailing address

PO BOX 332
LA HONDA CA
94020-0332
US

V. Phone/Fax

Practice location:
  • Phone: 650-799-4776
  • Fax:
Mailing address:
  • Phone: 650-799-4776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: JUANITA RENEE TRAVER STINE
Title or Position: OWNER
Credential: BCBA
Phone: 650-799-4776