Basic Information
| Provider Information | |||||||||
| NPI: | 1568439685 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEGACY BEHAVIORAL HEALTH CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 458 | ||||||||
| Address2: | |||||||||
| City: | INDIANTOWN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349560458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7725970411 | ||||||||
| FaxNumber: | 7725970412 | ||||||||
| Practice Location | |||||||||
| Address1: | 15818 SW WARFIELD BLVD | ||||||||
| Address2: | |||||||||
| City: | INDIANTOWN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349563513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7725970411 | ||||||||
| FaxNumber: | 7725970412 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 02/04/2020 | ||||||||
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| AuthorizedOfficialLastName: | PAJARES | ||||||||
| AuthorizedOfficialFirstName: | ALICIA | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5617227866 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | 02/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | SW5271 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 251S00000X | 6427 | FL | N | Agencies | Community/Behavioral Health | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 600058153 | 01 | FL | MAGELLAN HMO | OTHER | 076140100 | 05 | FL | MEDICAID |