Provider Demographics
NPI:1528733359
Name:LEGACY BEHAVIORAL HEALTH & WELLNESS
Entity type:Organization
Organization Name:LEGACY BEHAVIORAL HEALTH & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:MAYRA
Authorized Official - Middle Name:CRUZ
Authorized Official - Last Name:KOEDAM
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C, PMHNP-BC
Authorized Official - Phone:972-900-8640
Mailing Address - Street 1:3700 LEGACY DR APT 28206
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-6643
Mailing Address - Country:US
Mailing Address - Phone:972-900-8640
Mailing Address - Fax:
Practice Address - Street 1:8105 RASOR BLVD STE 248
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-0341
Practice Address - Country:US
Practice Address - Phone:469-461-1557
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEGACY BEHAVIORAL HEALTH & WELLNESS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-08-13
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty