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General NPI Number Information
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NPI Number | 1366240301
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Entity Type | Organization
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Legal Business Name | LEGACY VALLEY ADDICTION TREATMENT
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Dates
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Enumeration Date | 03/05/2025
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Last Update Date | 03/05/2025
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Provider Practice Location Address
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Address Line | 16519 VICTOR ST STE 302
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City | VICTORVILLE
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State | CA
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Zip | 92395-3967
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Country | US
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Telephone | 760-305-9677
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Fax |
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Provider Business Mailing Address
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Address Line | 12654 SEVENTH AVE
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City | VICTORVILLE
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State | CA
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Zip | 92395-9577
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Country | US
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Telephone | 760-912-5553
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Fax |
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | ANGELA L ABBOTT
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Credential | LMFT
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Telephone | 760-912-5553
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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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 | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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