Provider Demographics
NPI:1407227689
Name:LANDA, ELIZABETH (ATC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:LANDA
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22529 E 12 MILE RD APT 5
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-2502
Mailing Address - Country:US
Mailing Address - Phone:586-707-1192
Mailing Address - Fax:
Practice Address - Street 1:20952 E 12 MILE RD STE 110
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-3202
Practice Address - Country:US
Practice Address - Phone:313-432-3348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL8265592255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2601001454OtherSTATE OF MICHIGAN