Provider Demographics
NPI:1942325014
Name:LANDA, CARRIE ELIZABETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:CARRIE
Middle Name:ELIZABETH
Last Name:LANDA
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 1:1093 BEACON ST
Mailing Address - Street 2:SUITE 404
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-5695
Mailing Address - Country:US
Mailing Address - Phone:617-807-0738
Mailing Address - Fax:
Practice Address - Street 1:1093 BEACON ST
Practice Address - Street 2:SUITE 404
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-5695
Practice Address - Country:US
Practice Address - Phone:617-807-0738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9177103TC0700X
103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0017625Medicare Oscar/Certification