Provider Demographics
NPI:1548788714
Name:LANDER, MIA DASCHYLL
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:DASCHYLL
Last Name:LANDER
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 1:1333 S MAYFLOWER AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-5239
Mailing Address - Country:US
Mailing Address - Phone:818-241-6780
Mailing Address - Fax:888-588-2752
Practice Address - Street 1:330 GROVE ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-3909
Practice Address - Country:US
Practice Address - Phone:818-241-6780
Practice Address - Fax:888-588-2752
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-07
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3951103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst