Provider Demographics
NPI:1033601562
Name:THE LEGACY GROUP FOUNDATION, INC
Entity type:Organization
Organization Name:THE LEGACY GROUP FOUNDATION, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:DENICE
Authorized Official - Last Name:BARNES
Authorized Official - Suffix:
Authorized Official - Credentials:CSAC
Authorized Official - Phone:910-340-3630
Mailing Address - Street 1:8 CARVER RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-7010
Mailing Address - Country:US
Mailing Address - Phone:910-340-3630
Mailing Address - Fax:910-597-1007
Practice Address - Street 1:210 VANDEMERE RD UNIT A
Practice Address - Street 2:
Practice Address - City:BAYBORO
Practice Address - State:NC
Practice Address - Zip Code:28515-8010
Practice Address - Country:US
Practice Address - Phone:910-340-3630
Practice Address - Fax:910-597-1007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCSAC-3017101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty