Provider Demographics
NPI:1528493806
Name:LEGAN, REBECCA ANN
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANN
Last Name:LEGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1512 SUSSEX CT
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-7041
Mailing Address - Country:US
Mailing Address - Phone:612-743-5452
Mailing Address - Fax:
Practice Address - Street 1:1512 SUSSEX CT
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-7041
Practice Address - Country:US
Practice Address - Phone:612-743-5452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1041320-1-AFC253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency