Provider Demographics
NPI:1366240301
Name:LEGACY VALLEY ADDICTION TREATMENT
Entity type:Organization
Organization Name:LEGACY VALLEY ADDICTION TREATMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:L
Authorized Official - Last Name:ABBOTT
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:760-912-5553
Mailing Address - Street 1:12654 SEVENTH AVE
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-9577
Mailing Address - Country:US
Mailing Address - Phone:760-912-5553
Mailing Address - Fax:
Practice Address - Street 1:16519 VICTOR ST STE 302
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-3967
Practice Address - Country:US
Practice Address - Phone:760-305-9677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-05
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty