Healthcare Provider Details

I. General information

NPI: 1710019419
Provider Name (Legal Business Name): DAVID ALAN LEGENDRE PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2445 E MILTON AVE
YOUNGSVILLE LA
70592-5346
US

IV. Provider business mailing address

129 CLAREMONT CIR
LAFAYETTE LA
70508-7300
US

V. Phone/Fax

Practice location:
  • Phone: 337-856-1919
  • Fax: 337-856-1920
Mailing address:
  • Phone: 337-993-2706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number1912
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: