Healthcare Provider Details

I. General information

NPI: 1386479640
Provider Name (Legal Business Name): LEGACY HEALTH FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2024
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 E CITY HALL AVE STE 200B
NORFOLK VA
23510-1700
US

IV. Provider business mailing address

223 E CITY HALL AVE STE 200B
NORFOLK VA
23510-1700
US

V. Phone/Fax

Practice location:
  • Phone: 757-738-4959
  • Fax: 443-329-9452
Mailing address:
  • Phone: 804-963-5501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: CALVIN DEMOND WILLIAMS JR.
Title or Position: OWNER
Credential: CSAC-A
Phone: 804-963-5501