=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386056984
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EM LEGACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2014
-----------------------------------------------------
Last Update Date | 05/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2605 72ND AVE E 221
-----------------------------------------------------
City | ELLENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34222-7000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-545-9630
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2605 72ND AVE E 221
-----------------------------------------------------
City | ELLENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34222-7000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-545-9630
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MNGR DIRECTOR
-----------------------------------------------------
Name | MS. ERIN M PORTER
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 941-545-9630
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW11139
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------