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General NPI Number Information
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NPI Number | 1992248298
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Entity Type | Organization
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Legal Business Name | NEW LEGACY COUNSELING AND TRAINING CENTER
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Dates
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Enumeration Date | 11/18/2016
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Last Update Date | 11/18/2016
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Provider Practice Location Address
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Address Line | 3350 RIVERWOOD PARKWAY SUITE 1925
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City | ATLANTA
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State | GA
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Zip | 30339
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Country | US
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Telephone | 770-984-5341
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Fax | 404-549-4310
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Provider Business Mailing Address
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Address Line | 3350 RIVERWOOD PARKWAY SUITE 1925
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City | ATLANTA
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State | GA
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Zip | 30339
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Country | US
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Telephone | 770-984-5341
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Fax | 404-549-4310
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. TY WATSON SR.
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Credential | LPC
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Telephone | 404-889-2300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number | 005753
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License Number State | GA
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