Basic Information
| Provider Information | |||||||||
| NPI: | 1346267820 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEGACY PSYCHOLOGICAL SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 634927 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452630042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138912813 | ||||||||
| FaxNumber: | 5137931032 | ||||||||
| Practice Location | |||||||||
| Address1: | 7105 HAMILTON AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452315218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136999240 | ||||||||
| FaxNumber: | 5136818959 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 09/17/2009 | ||||||||
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| AuthorizedOfficialLastName: | GABIS | ||||||||
| AuthorizedOfficialFirstName: | JEROME | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5136999240 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PSYD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 103TA0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Adult Development & Aging | 104100000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 103TC0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 2922476 | 05 | OH | MEDICAID | DE6598 | 01 | RR MEDICARE | OTHER |