Provider Demographics
NPI:1356574339
Name:LANDRUM, OCTAVIA LASHAWN (PSYD)
Entity type:Individual
Prefix:DR
First Name:OCTAVIA
Middle Name:LASHAWN
Last Name:LANDRUM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:OCTAVIA
Other - Middle Name:LASHAWN
Other - Last Name:GARRETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:6453 LEADBETTER CT APT B
Mailing Address - Street 2:
Mailing Address - City:FORT POLK
Mailing Address - State:LA
Mailing Address - Zip Code:71459-8413
Mailing Address - Country:US
Mailing Address - Phone:214-274-1713
Mailing Address - Fax:
Practice Address - Street 1:1585 3RD ST
Practice Address - Street 2:
Practice Address - City:FORT POLK
Practice Address - State:LA
Practice Address - Zip Code:71459-5102
Practice Address - Country:US
Practice Address - Phone:337-531-3922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-25
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X, 101YM0800X
ALUNLICENSED103TC0700X
CAPSY26797103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical