Provider Demographics
NPI:1366571499
Name:LEGG, LARRY JACKSON (MA)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:JACKSON
Last Name:LEGG
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3883 FARMDALE RD
Mailing Address - Street 2:
Mailing Address - City:MEADOW BRIDGE
Mailing Address - State:WV
Mailing Address - Zip Code:25976-7035
Mailing Address - Country:US
Mailing Address - Phone:304-661-2742
Mailing Address - Fax:304-392-6835
Practice Address - Street 1:702 PROFESSIONAL PARK DR
Practice Address - Street 2:STE 106
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-2033
Practice Address - Country:US
Practice Address - Phone:304-883-2380
Practice Address - Fax:304-883-2383
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV630103TC0700X, 103TC1900X, 103TC2200X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities