Provider Demographics
NPI:1376564732
Name:IEVERS-LANDIS, CAROLYN E (PHD)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:E
Last Name:IEVERS-LANDIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24701 EUCLID AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5331103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000196535OtherANTHEM
OH341438215OtherAETNA
OH2238608Medicaid
OH000000196535OtherANTHEM
OHLACP25281Medicare ID - Type Unspecified
OHH094680Medicare PIN
OHP34436Medicare UPIN