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General NPI Number Information
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NPI Number | 1659193357
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Entity Type | Organization
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Legal Business Name | LEGACY BEHAVIORAL HEALTH CENTER
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Dates
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Enumeration Date | 10/25/2024
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Last Update Date | 10/25/2024
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Provider Practice Location Address
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Address Line | 518 SW PRIMA VISTA BLVD
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City | PORT ST LUCIE
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State | FL
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Zip | 34983-8734
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Country | US
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Telephone | 772-873-8811
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Fax | 772-873-8800
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Provider Business Mailing Address
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Address Line | 518 SW PRIMA VISTA BLVD
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City | PORT ST LUCIE
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State | FL
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Zip | 34983-8734
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Country | US
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Telephone | 772-873-8811
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Fax | 772-873-8800
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Authorized Official
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Title or Position | HR DIRECTOR
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Name | IVAN RAFAEL JIMENEZ
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Credential |
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Telephone | 561-253-1770
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State |
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