Provider Demographics
NPI:1134644578
Name:LAND, THERESA (LCSW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:LAND
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 ORCHARD LN
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-7547
Mailing Address - Country:US
Mailing Address - Phone:912-548-2099
Mailing Address - Fax:
Practice Address - Street 1:2484 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31503-6336
Practice Address - Country:US
Practice Address - Phone:912-548-2099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-07
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0047151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical