Provider Demographics
NPI:1104704832
Name:LEGACY BEHAVIORAL GROUP
Entity type:Organization
Organization Name:LEGACY BEHAVIORAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROMINA
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:740-590-4347
Mailing Address - Street 1:958 TRADEWINDS CV
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-4698
Mailing Address - Country:US
Mailing Address - Phone:740-590-4347
Mailing Address - Fax:216-714-7997
Practice Address - Street 1:958 TRADEWINDS CV
Practice Address - Street 2:
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077-4698
Practice Address - Country:US
Practice Address - Phone:740-590-4347
Practice Address - Fax:216-714-7997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-21
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty