Provider Demographics
NPI:1972919561
Name:LANDRON, MARJORIE VIELKA (LSW)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:VIELKA
Last Name:LANDRON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S WOODLAND ST
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-3546
Mailing Address - Country:US
Mailing Address - Phone:407-905-8827
Mailing Address - Fax:407-905-8827
Practice Address - Street 1:840 MERCY DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32808-7820
Practice Address - Country:US
Practice Address - Phone:407-905-8827
Practice Address - Fax:407-209-3220
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-03
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW206461041C0700X
NV8054-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV460732507Medicaid