Provider Demographics
NPI:1760052013
Name:LANDERS, MARY THERESE (LP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:THERESE
Last Name:LANDERS
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 EAST 72ND STREET
Mailing Address - Street 2:#2J
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4644
Mailing Address - Country:US
Mailing Address - Phone:646-201-8053
Mailing Address - Fax:212-861-0199
Practice Address - Street 1:355 EAST 72ND STREET
Practice Address - Street 2:#2J
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4644
Practice Address - Country:US
Practice Address - Phone:646-201-8053
Practice Address - Fax:212-861-0199
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1077102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalystGroup - Multi-Specialty