Provider Demographics
NPI:1043383805
Name:LANDRUM, LANA R (PHD)
Entity Type:Individual
Prefix:DR
First Name:LANA
Middle Name:R
Last Name:LANDRUM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 LOS ALAMOS HWY
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2731
Mailing Address - Country:US
Mailing Address - Phone:505-753-0773
Mailing Address - Fax:505-753-0775
Practice Address - Street 1:243 LOS ALAMOS HWY
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2731
Practice Address - Country:US
Practice Address - Phone:505-753-0773
Practice Address - Fax:505-753-0775
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM758103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM63939OtherPRESBYTERIAN HEALTH PLAN
NMNM100034Medicaid