Organization
LEGACY WELLNESS SERVICES LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
NICOLE LEWIS LCSW, LICSW (CLINICAL DIRECTOR)
(228) 231-0516
Entity
Organization
Contact information
Practice address
6068 US HWY 98 WEST, HATTIESBURG, MS 39402
(228) 231-0516
Mailing address
6068 US HWY 98 WEST, STE 1 BOX 304, HATTIESBURG, MS 39402
(228) 231-0516
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
—
—
261QM0850X
Adult Mental Health Clinic/Center
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
NONE
BLUE CROSS BLUE SHIELD
—
Enumeration date
07/15/2021
Last updated
07/15/2021
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