Provider Demographics
NPI:1417702366
Name:LEGACY SPORTS AND SEL STRATEGIES LLC
Entity type:Organization
Organization Name:LEGACY SPORTS AND SEL STRATEGIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALPHONSO
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:SHEPHERD
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:646-594-4281
Mailing Address - Street 1:2 MALLORY CT
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:DE
Mailing Address - Zip Code:19720-8852
Mailing Address - Country:US
Mailing Address - Phone:646-594-4281
Mailing Address - Fax:
Practice Address - Street 1:2 MALLORY CT
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:DE
Practice Address - Zip Code:19720-8852
Practice Address - Country:US
Practice Address - Phone:646-594-4281
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-23
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty