Healthcare Provider Details

I. General information

NPI: 1770510075
Provider Name (Legal Business Name): LEGACY COUNSELING CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 05/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4054 MCKINNEY AVE STE 102
DALLAS TX
75204-2050
US

IV. Provider business mailing address

4054 MCKINNEY AVE STE 102
DALLAS TX
75204-2050
US

V. Phone/Fax

Practice location:
  • Phone: 214-520-6308
  • Fax:
Mailing address:
  • Phone: 214-520-6308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberS18803
License Number StateTX

VIII. Authorized Official

Name: MELISSA GROVE
Title or Position: EXECUTIVE DIRECTOR
Credential: LPC, M.S.
Phone: 214-520-6308