MEDICARE: LEGACY COUNSELING AND WORKFORCE CONNECTIONS

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	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1760027213
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY COUNSELING AND WORKFORCE CONNECTIONS

Provider Business Mailing Address
First Line	:	4170 S DECATUR BLVD STE 9
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-5861
Country	:	US
Telephone Number	:	702-763-7443
Fax Number	:	866-284-1860

Provider Business Practice Location Address
First Line	:	4170 S DECATUR BLVD STE 9
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-5861
Country	:	US
Telephone Number	:	702-763-7443
Fax Number	:	866-284-1860

Authorized Official
Title or Position	:	CEO
Name	:	CHRIS A DOSS
Credential	:
Telephone Number	:	702-763-7443

Provider Enumeration Date	:	11/07/2019
Last Update Date	:	04/16/2020

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