Provider Demographics
NPI:1710420351
Name:LANDRUM, MELINDA
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:
Last Name:LANDRUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MINDY
Other - Middle Name:
Other - Last Name:LANDRUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10519 VAUGHN RD
Mailing Address - Street 2:
Mailing Address - City:PIKE ROAD
Mailing Address - State:AL
Mailing Address - Zip Code:36064-2700
Mailing Address - Country:US
Mailing Address - Phone:334-603-1427
Mailing Address - Fax:
Practice Address - Street 1:10519 VAUGHN RD
Practice Address - Street 2:
Practice Address - City:PIKE ROAD
Practice Address - State:AL
Practice Address - Zip Code:36064-2700
Practice Address - Country:US
Practice Address - Phone:334-603-1427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-30
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALC2642A101Y00000X
AL3703101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL814527338Medicaid