Provider Demographics
NPI:1902022627
Name:VAN LANDINGHAM, CAROL JANE (LICSW)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:JANE
Last Name:VAN LANDINGHAM
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 MERRIMACK ST
Mailing Address - Street 2:
Mailing Address - City:HAVERHILL
Mailing Address - State:MA
Mailing Address - Zip Code:01830-6207
Mailing Address - Country:US
Mailing Address - Phone:978-373-1126
Mailing Address - Fax:978-373-6363
Practice Address - Street 1:60 MERRIMACK ST
Practice Address - Street 2:
Practice Address - City:HAVERHILL
Practice Address - State:MA
Practice Address - Zip Code:01830-6207
Practice Address - Country:US
Practice Address - Phone:978-373-1126
Practice Address - Fax:978-373-6363
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1074651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1312294Medicaid
MAHEP10093Medicare UPIN
MAP20940Medicare ID - Type Unspecified