MEDICARE: LEGACY FAMILY SERVICES INC.

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	101YP2500X	Professional Counselor	5636	OK

General Provider Information

NPI Number	:	1902270267
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY FAMILY SERVICES INC.

Provider Business Mailing Address
First Line	:	11901 N MACARTHUR BLVD
Second Line	:	SUITE C
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73162-1806
Country	:	US
Telephone Number	:	405-202-1027
Fax Number	:

Provider Business Practice Location Address
First Line	:	11901 N MACARTHUR BLVD
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73162-1806
Country	:	US
Telephone Number	:	405-202-1027
Fax Number	:

Authorized Official
Title or Position	:	LICENSED PROFESSIONAL COUNSELOR
Name	:	ASHLEY BRYANT
Credential	:	MS, LPC
Telephone Number	:	405-202-1027

Provider Enumeration Date	:	11/23/2015
Last Update Date	:	12/30/2015

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