MEDICARE: AMANDA JEANNE LEGG MS, ADC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor		CA
2	101Y00000X	Counselor	CATC-I #3025	CA

General Provider Information

NPI Number	:	1790117877
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA JEANNE LEGG MS, ADC

Provider Business Mailing Address
First Line	:	3250 SWEETWATER RD APT 1605
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30044-6519
Country	:	US
Telephone Number	:	423-794-6525
Fax Number	:

Provider Business Practice Location Address
First Line	:	3390 N BERKELEY LAKE RD NW STE 100
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30096-3006
Country	:	US
Telephone Number	:	470-704-5050
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2013
Last Update Date	:	06/16/2023

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