Basic Information
| Provider Information | |||||||||
| NPI: | 1134465610 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEGACY BEHAVIORAL HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2640 FOREST HILL BLVD | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334065931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616168411 | ||||||||
| FaxNumber: | 6161684125 | ||||||||
| Practice Location | |||||||||
| Address1: | 233 W AVENUE A STE C | ||||||||
| Address2: | |||||||||
| City: | BELLE GLADE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334303092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5612533679 | ||||||||
| FaxNumber: | 5612533680 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2013 | ||||||||
| LastUpdateDate: | 08/24/2021 | ||||||||
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| AuthorizedOfficialLastName: | PAJARES | ||||||||
| AuthorizedOfficialFirstName: | ALICIA | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5617227866 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | 08/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 110114100 | 01 | FL | 91 - MEDICAID | OTHER |