Provider Demographics
NPI:1063427417
Name:LEGG, TIMOTHY JAMES (PHD, PSYD, CRNP)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JAMES
Last Name:LEGG
Suffix:
Gender:M
Credentials:PHD, PSYD, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-1684
Mailing Address - Country:US
Mailing Address - Phone:570-682-5777
Mailing Address - Fax:570-284-3078
Practice Address - Street 1:421 S STATE ST
Practice Address - Street 2:
Practice Address - City:CLARKS SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18411-1684
Practice Address - Country:US
Practice Address - Phone:570-682-5777
Practice Address - Fax:570-284-3078
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP-006515-H363LG0600X
PASP013800363LP0808X
PAPS019448103TC0700X
NYF401677363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400134083Medicare PIN