Healthcare Provider Details

I. General information

NPI: 1114519360
Provider Name (Legal Business Name): LEGEND PSYCH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2021
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 KINDERKAMACK RD STE 108
ORADELL NJ
07649-1500
US

IV. Provider business mailing address

239 PROSPECT AVE APT 1
NEW MILFORD NJ
07646-1764
US

V. Phone/Fax

Practice location:
  • Phone: 201-523-4113
  • Fax:
Mailing address:
  • Phone: 201-523-4113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. BLAKE W JONAS
Title or Position: OWNER
Credential: LMFT
Phone: 201-523-4113