MEDICARE: LEGACY COUNSELING SERVICE

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	103T00000X	Psychologist	1268	OK

General Provider Information

NPI Number	:	1205377678
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY COUNSELING SERVICE

Provider Business Mailing Address
First Line	:	6406 E FORT WORTH PL
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74014-7043
Country	:	US
Telephone Number	:	918-505-4367
Fax Number	:	888-371-9410

Provider Business Practice Location Address
First Line	:	2035A WEST HOUSTON STREET
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-8792
Country	:	US
Telephone Number	:	918-505-4367
Fax Number	:	888-371-9410

Authorized Official
Title or Position	:	OWNER/OPERTOR
Name	:	DR. MELISSA JEAN LEEDY
Credential	:	PH.D.
Telephone Number	:	918-505-4367

Provider Enumeration Date	:	03/17/2017
Last Update Date	:	09/04/2022

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