Healthcare Provider Details

I. General information

NPI: 1275212573
Provider Name (Legal Business Name): LEGACY COMMUNITY SOLUTIONS INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2023
Last Update Date: 01/25/2024
Certification Date: 01/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 S HOSPITAL DR STE 100
PLANTATION FL
33317-2831
US

IV. Provider business mailing address

4100 S HOSPITAL DR STE 100
PLANTATION FL
33317-2831
US

V. Phone/Fax

Practice location:
  • Phone: 954-769-1055
  • Fax: 954-533-1739
Mailing address:
  • Phone: 954-769-1055
  • Fax: 954-533-1739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: LEOLA WITHERSPOON
Title or Position: PRESIDENT
Credential:
Phone: 954-274-1053