Provider Demographics
NPI:1518578970
Name:LANDAVERDE, LAURA MARGARITA
Entity Type:Individual
Prefix:MISS
First Name:LAURA
Middle Name:MARGARITA
Last Name:LANDAVERDE
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 1:1950 S SUNWEST LN STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3248
Mailing Address - Country:US
Mailing Address - Phone:909-252-4017
Mailing Address - Fax:818-241-6853
Practice Address - Street 1:1330 E COOLEY DR # 92324
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3905
Practice Address - Country:US
Practice Address - Phone:909-580-3728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2023-10-02
Deactivation Date:2022-04-19
Deactivation Code:
Reactivation Date:2022-05-12
Provider Licenses
StateLicense IDTaxonomies
CA140136106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist