=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013342773
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE LEGGETT GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2013
-----------------------------------------------------
Last Update Date | 09/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4238 WASHINGTON ST STE 316
-----------------------------------------------------
City | ROSLINDALE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02131-2517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-851-0171
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4238 WASHINGTON ST STE 316
-----------------------------------------------------
City | ROSLINDALE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02131-2517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-851-0171
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER AND DIRECTOR
-----------------------------------------------------
Name | JENNIFER ALYSSA ERBE LEGGETT
-----------------------------------------------------
Credential | LICSW
-----------------------------------------------------
Telephone | 617-851-0171
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 111254
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------