Provider Demographics
NPI:1376133223
Name:LANDESTOY, TALINA RODRIGUEZ
Entity Type:Individual
Prefix:
First Name:TALINA
Middle Name:RODRIGUEZ
Last Name:LANDESTOY
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 1:2910 EVANS MILL RD # B83
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-2481
Mailing Address - Country:US
Mailing Address - Phone:404-788-8094
Mailing Address - Fax:
Practice Address - Street 1:2910 EVANS MILL RD
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-2481
Practice Address - Country:US
Practice Address - Phone:404-500-8387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-25
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC007677101YM0800X
1403101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)