Provider Demographics
NPI:1710256433
Name:LAND, ALEXIS N (LCSW)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:N
Last Name:LAND
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4316 WATERFORD VALLEY CIR
Mailing Address - Street 2:337
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-3117
Mailing Address - Country:US
Mailing Address - Phone:704-787-6017
Mailing Address - Fax:
Practice Address - Street 1:145 SCALEYBARK RD
Practice Address - Street 2:SUITE B
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-2687
Practice Address - Country:US
Practice Address - Phone:704-608-3839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-26
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0076401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6009045Medicaid