Provider Demographics
NPI:1114399383
Name:LEGG, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:LEGG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 RIVER RD STE 106
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:07020-1002
Mailing Address - Country:US
Mailing Address - Phone:201-606-2592
Mailing Address - Fax:
Practice Address - Street 1:125 RIVER RD STE 106
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:07020-1002
Practice Address - Country:US
Practice Address - Phone:201-606-2592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-27
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA017910103T00000X
NJ35SI00557600103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist