MEDICARE: LEGACY HOLISTIC THERAPY PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1023901592
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY HOLISTIC THERAPY PLLC

Provider Business Mailing Address
First Line	:	5818 HIGHLAND SHOPPES DR STE C5
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-2654
Country	:	US
Telephone Number	:	980-319-8197
Fax Number	:	980-734-3473

Provider Business Practice Location Address
First Line	:	10215 HICKORYWOOD HILL AVE
Second Line	:
City	:	HUNTERVILLE
State	:	NC
Zip	:	28078
Country	:	US
Telephone Number	:	980-319-8197
Fax Number	:	980-734-3473

Authorized Official
Title or Position	:	OWNER
Name	:	TINA TUTTLE
Credential	:	LCMHCA
Telephone Number	:	980-319-8197

Provider Enumeration Date	:	06/02/2025
Last Update Date	:	06/02/2025

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