Healthcare Provider Details

I. General information

NPI: 1336770627
Provider Name (Legal Business Name): LEGACY'S IMPACT INTERVENTION L.L.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2020
Last Update Date: 01/27/2020
Certification Date: 01/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3606 IDAHO AVE
BARTLESVILLE OK
74006-2420
US

IV. Provider business mailing address

3606 IDAHO AVE
BARTLESVILLE OK
74006-2420
US

V. Phone/Fax

Practice location:
  • Phone: 918-766-6998
  • Fax:
Mailing address:
  • Phone: 918-766-6998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
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 Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: SHONTA CROWDER
Title or Position: DIRECTOR/THERAPIST
Credential: LCSW
Phone: 918-766-6998