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General NPI Number Information
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NPI Number | 1205377678
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Entity Type | Organization
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Legal Business Name | LEGACY COUNSELING SERVICE
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Dates
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Enumeration Date | 03/17/2017
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Last Update Date | 09/04/2022
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Provider Practice Location Address
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Address Line | 2035A WEST HOUSTON STREET
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City | BROKEN ARROW
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State | OK
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Zip | 74012-8792
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Country | US
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Telephone | 918-505-4367
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Fax | 888-371-9410
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Provider Business Mailing Address
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Address Line | 6406 E FORT WORTH PL
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City | BROKEN ARROW
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State | OK
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Zip | 74014-7043
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Country | US
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Telephone | 918-505-4367
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Fax | 888-371-9410
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Authorized Official
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Title or Position | OWNER/OPERTOR
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Name | DR. MELISSA JEAN LEEDY
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Credential | PH.D.
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Telephone | 918-505-4367
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 1268
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License Number State | OK
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