Provider Demographics
NPI:1164735775
Name:LAND, THERESA STEPAN (LICSW)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:STEPAN
Last Name:LAND
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5112 FOREST RD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-4328
Mailing Address - Country:US
Mailing Address - Phone:952-949-6631
Mailing Address - Fax:
Practice Address - Street 1:1405 LILAC DR N
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-4535
Practice Address - Country:US
Practice Address - Phone:763-525-9919
Practice Address - Fax:763-486-4439
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-23
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN126051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical