Provider Demographics
NPI:1992248298
Name:NEW LEGACY COUNSELING AND TRAINING CENTER
Entity type:Organization
Organization Name:NEW LEGACY COUNSELING AND TRAINING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TY
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:SR
Authorized Official - Credentials:LPC
Authorized Official - Phone:404-889-2300
Mailing Address - Street 1:3350 RIVERWOOD PARKWAY
Mailing Address - Street 2:SUITE 1925
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339
Mailing Address - Country:US
Mailing Address - Phone:770-984-5341
Mailing Address - Fax:404-549-4310
Practice Address - Street 1:3350 RIVERWOOD PARKWAY
Practice Address - Street 2:SUITE 1925
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339
Practice Address - Country:US
Practice Address - Phone:770-984-5341
Practice Address - Fax:404-549-4310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-18
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005753305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service