Provider Demographics
NPI:1598144636
Name:SELF, LANDON
Entity Type:Individual
Prefix:
First Name:LANDON
Middle Name:
Last Name:SELF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 TIMBER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-4233
Mailing Address - Country:US
Mailing Address - Phone:901-566-1002
Mailing Address - Fax:901-566-1951
Practice Address - Street 1:58 TIMBER CREEK DR
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-4233
Practice Address - Country:US
Practice Address - Phone:901-566-1002
Practice Address - Fax:901-566-1951
Is Sole Proprietor?:No
Enumeration Date:2015-05-21
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3058101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional