Healthcare Provider Details

I. General information

NPI: 1366571499
Provider Name (Legal Business Name): LARRY JACKSON LEGG M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 01/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 PROFESSIONAL PARK DR STE 106
SUMMERSVILLE WV
26651-2033
US

IV. Provider business mailing address

3883 FARMDALE RD
MEADOW BRIDGE WV
25976-7035
US

V. Phone/Fax

Practice location:
  • Phone: 304-883-2380
  • Fax: 304-883-2383
Mailing address:
  • Phone: 304-661-2742
  • Fax: 304-392-6835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number630
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number630
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number630
License Number StateWV
# 4
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number630
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: