Provider Demographics
NPI:1174396980
Name:KA LEGACY INC
Entity type:Organization
Organization Name:KA LEGACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRISSOM-TATROE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:870-919-6585
Mailing Address - Street 1:103 W FLEEMAN
Mailing Address - Street 2:BOX 835
Mailing Address - City:MANILA
Mailing Address - State:AR
Mailing Address - Zip Code:72442
Mailing Address - Country:US
Mailing Address - Phone:870-919-6585
Mailing Address - Fax:
Practice Address - Street 1:103 W FLEEMAN
Practice Address - Street 2:
Practice Address - City:MANILA
Practice Address - State:AR
Practice Address - Zip Code:72442
Practice Address - Country:US
Practice Address - Phone:870-919-6585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-02
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR429713402OtherBCBS
AR429713402OtherUNITED HEALTH