=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609765742
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEGACY WELLNESS MENTAL HEALTH SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2025
-----------------------------------------------------
Last Update Date | 07/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1385 FORDHAM DR STE 105-138
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23464-5345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-724-0351
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1385 FORDHAM DR STE 105-138
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23464-5345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-563-3378
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KIESHARA A MATTHEWS
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 757-724-0351
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------