Provider Demographics
NPI:1255867578
Name:LANDAU, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
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 1:1907 SLIGO CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32826-5206
Mailing Address - Country:US
Mailing Address - Phone:516-369-4307
Mailing Address - Fax:
Practice Address - Street 1:1513 S KIRKMAN RD
Practice Address - Street 2:1113
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32811-2631
Practice Address - Country:US
Practice Address - Phone:321-287-0352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-05
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020233800Medicaid