Basic Information
| Provider Information | |||||||||
| NPI: | 1730486721 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEGACY BEHAVIORAL HEALTH CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1551 FORUM PL | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334012319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616168411 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1945 22ND AVE | ||||||||
| Address2: | |||||||||
| City: | VERO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329603083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722575264 | ||||||||
| FaxNumber: | 7722575625 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2011 | ||||||||
| LastUpdateDate: | 03/16/2011 | ||||||||
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| AuthorizedOfficialLastName: | PAJARES | ||||||||
| AuthorizedOfficialFirstName: | ALICIA | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 5616168411 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MH0002973 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.