Provider Demographics
NPI:1205219763
Name:THIRD WAVE PSYCHOTHERAPY, PLLC
Entity Type:Organization
Organization Name:THIRD WAVE PSYCHOTHERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LANDAAS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:919-923-8752
Mailing Address - Street 1:5401 SIX FORKS RD STE 200
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-4462
Mailing Address - Country:US
Mailing Address - Phone:919-886-4052
Mailing Address - Fax:
Practice Address - Street 1:5401 SIX FORKS RD STE 200
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-4462
Practice Address - Country:US
Practice Address - Phone:919-886-4052
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-02
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0077211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty