Provider Demographics
NPI:1205265923
Name:LANDIS, MARK DOUGLAS (PSYD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DOUGLAS
Last Name:LANDIS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 RESEARCH PKWY
Mailing Address - Street 2:
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-4214
Mailing Address - Country:US
Mailing Address - Phone:800-370-3651
Mailing Address - Fax:877-515-7147
Practice Address - Street 1:901 DULANEY VALLEY RD
Practice Address - Street 2:SUITE 129
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-2600
Practice Address - Country:US
Practice Address - Phone:888-818-6595
Practice Address - Fax:410-832-5783
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03548103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical