Healthcare Provider Details

I. General information

NPI: 1114483658
Provider Name (Legal Business Name): LEGACY COUNSELING AND CONSULTING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2019
Last Update Date: 06/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3790 OLD US 41 N STE A
VALDOSTA GA
31602-6865
US

IV. Provider business mailing address

4986 SUMMIT RIDGE RD
VALDOSTA GA
31602
US

V. Phone/Fax

Practice location:
  • Phone: 229-262-1000
  • Fax:
Mailing address:
  • Phone: 229-630-5982
  • 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: MRS. RACHAEL DUDLEY
Title or Position: OWNER
Credential: LCSW
Phone: 229-630-5982