Healthcare Provider Details

I. General information

NPI: 1679352892
Provider Name (Legal Business Name): LEGACY KIDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2023
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1213 AVIATOR LN S
TUSTIN CA
92782-1701
US

IV. Provider business mailing address

1213 AVIATOR LN S
TUSTIN CA
92782-1701
US

V. Phone/Fax

Practice location:
  • Phone: 949-412-5939
  • Fax:
Mailing address:
  • Phone: 949-412-5939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. MISTY M WEI
Title or Position: OWNER/DIRECTOR
Credential: BCBA
Phone: 949-412-5939