Provider Demographics
NPI:1134815905
Name:LANDA, MATTHEW (LCSW)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:LANDA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4719 S GREENWOOD AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-1984
Mailing Address - Country:US
Mailing Address - Phone:312-933-1865
Mailing Address - Fax:
Practice Address - Street 1:4719 S GREENWOOD AVE APT 3
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-1984
Practice Address - Country:US
Practice Address - Phone:312-933-1865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-14
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490128391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical