Basic Information
| Provider Information | |||||||||
| NPI: | 1477828887 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEGACY BEHAVIORAL HEALTH CENTER, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1551 FORUM PL | ||||||||
| Address2: | 400 D&E | ||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334012319 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1945 22ND AVE | ||||||||
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| City: | VERO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329603083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7726461682 | ||||||||
| FaxNumber: | 7722575265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2012 | ||||||||
| LastUpdateDate: | 03/19/2012 | ||||||||
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| AuthorizedOfficialLastName: | JIMENEZ | ||||||||
| AuthorizedOfficialFirstName: | IVAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | HUMAN RESOURCES | ||||||||
| AuthorizedOfficialTelephone: | 5617128821 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.