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General NPI Number Information
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NPI Number | 1114519360
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Entity Type | Organization
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Legal Business Name | LEGEND PSYCH LLC
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Dates
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Enumeration Date | 02/09/2021
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Last Update Date | 05/27/2021
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Provider Practice Location Address
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Address Line | 550 KINDERKAMACK RD STE 108
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City | ORADELL
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State | NJ
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Zip | 07649-1500
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Country | US
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Telephone | 201-523-4113
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Fax |
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Provider Business Mailing Address
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Address Line | 239 PROSPECT AVE APT 1
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City | NEW MILFORD
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State | NJ
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Zip | 07646-1764
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Country | US
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Telephone | 201-523-4113
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. BLAKE W JONAS
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Credential | LMFT
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Telephone | 201-523-4113
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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