Healthcare Provider Details

I. General information

NPI: 1134571375
Provider Name (Legal Business Name): ANGELA LEGNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2016
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3821 WOODBRIAR TRL STE 105
PORT ORANGE FL
32129-9615
US

IV. Provider business mailing address

3821 WOODBRIAR TRL STE 105
PORT ORANGE FL
32129-9615
US

V. Phone/Fax

Practice location:
  • Phone: 386-317-0062
  • Fax: 386-401-2424
Mailing address:
  • Phone: 386-317-0062
  • Fax: 386-401-2424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberMH-24320
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6141-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: