Healthcare Provider Details

I. General information

NPI: 1336004746
Provider Name (Legal Business Name): NEW LEGACY BEHAVIORAL HEALTH LICENSED PROFESSIONAL CLINICAL COUNSELOR INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24904 LEAR LN
MORENO VALLEY CA
92553-5875
US

IV. Provider business mailing address

24904 LEAR LN
MORENO VALLEY CA
92553-5875
US

V. Phone/Fax

Practice location:
  • Phone: 661-742-4026
  • Fax:
Mailing address:
  • Phone: 661-742-4026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: JASMINE MIMS
Title or Position: CEO
Credential: LPCC
Phone: 661-742-4026