Healthcare Provider Details

I. General information

NPI: 1932371655
Provider Name (Legal Business Name): FAMILY LEGACY MENTAL HEALTH SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2008
Last Update Date: 06/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 BROAD ST
DURHAM NC
27705-4143
US

IV. Provider business mailing address

1011 SCHAUB DR SUITE 200
RALEIGH NC
27606-1862
US

V. Phone/Fax

Practice location:
  • Phone: 919-834-2000
  • Fax: 919-834-2001
Mailing address:
  • Phone: 919-834-2000
  • Fax: 919-834-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6102775
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6107485
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6001168
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number6105171
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number9300596
License Number StateNC
# 6
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: LISA DYAN STACEY
Title or Position: CEO
Credential: B.S. Q.P
Phone: 919-834-2000