Provider Demographics
NPI:1538330261
Name:LANDA, MATTY
Entity Type:Individual
Prefix:
First Name:MATTY
Middle Name:
Last Name:LANDA
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 1:9500 ETIWANDA AVE
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-9662
Mailing Address - Country:US
Mailing Address - Phone:909-463-5234
Mailing Address - Fax:
Practice Address - Street 1:9500 ETIWANDA AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-9662
Practice Address - Country:US
Practice Address - Phone:909-463-5021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-20
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW633061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical