Healthcare Provider Details

I. General information

NPI: 1841765393
Provider Name (Legal Business Name): LEGACY TREATMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2018
Last Update Date: 10/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8610 WASHINGTON BLVD
JESSUP MD
20794-9499
US

IV. Provider business mailing address

8610 WASHINGTON BLVD STE 200
JESSUP MD
20794-9499
US

V. Phone/Fax

Practice location:
  • Phone: 410-824-8149
  • Fax: 410-824-8371
Mailing address:
  • Phone: 410-824-8149
  • Fax: 410-824-8371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: LLOYD A WYNN
Title or Position: COO
Credential:
Phone: 973-558-8514