Healthcare Provider Details

I. General information

NPI: 1427666106
Provider Name (Legal Business Name): LEGACY COUNSELING SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2020
Last Update Date: 07/17/2020
Certification Date: 07/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 WINDBROOK CIR
NEWPORT NEWS VA
23602-8847
US

IV. Provider business mailing address

622 WINDBROOK CIR
NEWPORT NEWS VA
23602-8847
US

V. Phone/Fax

Practice location:
  • Phone: 804-677-0223
  • Fax:
Mailing address:
  • Phone: 804-677-0223
  • Fax: 804-210-1550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. EBONY NICKENS
Title or Position: OWNER
Credential:
Phone: 804-677-0223