Healthcare Provider Details

I. General information

NPI: 1912579202
Provider Name (Legal Business Name): LEGACY WELLNESS SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2021
Last Update Date: 07/15/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6068 US HWY 98 WEST
HATTIESBURG MS
39402
US

IV. Provider business mailing address

6068 US HWY 98 WEST STE 1 BOX 304
HATTIESBURG MS
39402
US

V. Phone/Fax

Practice location:
  • Phone: 228-231-0516
  • Fax:
Mailing address:
  • Phone: 228-231-0516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NICOLE LEWIS
Title or Position: CLINICAL DIRECTOR
Credential: LCSW, LICSW
Phone: 228-231-0516