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General NPI Number Information
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NPI Number | 1215473657
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Entity Type | Organization
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Legal Business Name | LEGACY FAMILY SERVICES
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Dates
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Enumeration Date | 01/09/2017
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Last Update Date | 01/09/2017
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Provider Practice Location Address
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Address Line | 2205 WIDE RIVER DR
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City | RALEIGH
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State | NC
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Zip | 27614-7612
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Country | US
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Telephone | 919-931-1634
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Fax |
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Provider Business Mailing Address
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Address Line | 2205 WIDE RIVER DR
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City | RALEIGH
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State | NC
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Zip | 27614-7612
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Country | US
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Telephone | 919-931-1634
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | KEEMIA H SHAW
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Credential | LCSW
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Telephone | 919-931-1634
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number | C006436
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number | C006436
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License Number State | NC
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Taxonomy #3
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number | COO6436
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License Number State | NC
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Taxonomy #4
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | C006436
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License Number State | NC
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