Provider Demographics
NPI:1093357170
Name:LANDAU, STEFANIE ALYSON
Entity Type:Individual
Prefix:DR
First Name:STEFANIE
Middle Name:ALYSON
Last Name:LANDAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 WATER ST STE 203
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4225
Mailing Address - Country:US
Mailing Address - Phone:617-315-8856
Mailing Address - Fax:
Practice Address - Street 1:112 WATER ST STE 203
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02109-4225
Practice Address - Country:US
Practice Address - Phone:617-315-8856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-10
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEB1-0001200103T00000X
MA11204103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist