Provider Demographics
NPI:1609828458
Name:LAND, AVA C (PHD)
Entity Type:Individual
Prefix:DR
First Name:AVA
Middle Name:C
Last Name:LAND
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 NE 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34470-5368
Mailing Address - Country:US
Mailing Address - Phone:352-873-4441
Mailing Address - Fax:
Practice Address - Street 1:1135 NE 8TH AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34470-5368
Practice Address - Country:US
Practice Address - Phone:352-873-4441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4857103TC0700X
FLPY 4857103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59485Medicare ID - Type Unspecified