Healthcare Provider Details

I. General information

NPI: 1275119869
Provider Name (Legal Business Name): LEGACY HEALING AND TREATMENT NEW JERSEY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 03/26/2021
Certification Date: 03/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 KINGS HWY N STE 100
CHERRY HILL NJ
08034-1585
US

IV. Provider business mailing address

2960 N STATE ROAD 7 STE 101
MARGATE FL
33063-5756
US

V. Phone/Fax

Practice location:
  • Phone: 609-267-5656
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: DAMARIS GONZALEZ
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 561-308-0865