Basic Information
| Provider Information | |||||||||
| NPI: | 1770886954 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY LEGACY MENTAL HEALTH SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1011 SCHAUB DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276061862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198342000 | ||||||||
| FaxNumber: | 9198342001 | ||||||||
| Practice Location | |||||||||
| Address1: | 1011 SCHAUB DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276061862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198342000 | ||||||||
| FaxNumber: | 9198342001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2010 | ||||||||
| LastUpdateDate: | 01/27/2014 | ||||||||
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| AuthorizedOfficialLastName: | STACEY | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | DYAN | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9198342000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | B.S. Q.P | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | N | Agencies | Case Management | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 3410107 | 05 | NC | MEDICAID | 8703109 | 05 | NC | MEDICAID |