Healthcare Provider Details

I. General information

NPI: 1790117877
Provider Name (Legal Business Name): AMANDA JEANNE LEGG MS, ADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2013
Last Update Date: 06/16/2023
Certification Date: 06/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3390 N BERKELEY LAKE RD NW STE 100
DULUTH GA
30096-3006
US

IV. Provider business mailing address

3250 SWEETWATER RD APT 1605
LAWRENCEVILLE GA
30044-6519
US

V. Phone/Fax

Practice location:
  • Phone: 470-704-5050
  • Fax:
Mailing address:
  • Phone: 423-794-6525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCATC-I #3025
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: