Provider Demographics
NPI:1083420244
Name:LEGACY MENTAL HEALTH SERVICES PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:LEGACY MENTAL HEALTH SERVICES PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TYISHA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:FLETCHER
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:702-605-7018
Mailing Address - Street 1:12267 HARVEST SKY WAY UNIT 3
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89183-5974
Mailing Address - Country:US
Mailing Address - Phone:310-251-6727
Mailing Address - Fax:
Practice Address - Street 1:2850 W HORIZON RIDGE PKWY STE 200
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4395
Practice Address - Country:US
Practice Address - Phone:702-605-7018
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-03
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty