Provider Demographics
NPI:1750160669
Name:LANDIS, KATY TARA (MA, ED S, LEP#4191)
Entity type:Individual
Prefix:
First Name:KATY
Middle Name:TARA
Last Name:LANDIS
Suffix:
Gender:F
Credentials:MA, ED S, LEP#4191
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8880 RIO SAN DIEGO DR FL 8
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-1642
Mailing Address - Country:US
Mailing Address - Phone:619-500-6282
Mailing Address - Fax:
Practice Address - Street 1:8880 RIO SAN DIEGO DR FL 8
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1642
Practice Address - Country:US
Practice Address - Phone:619-500-6282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-28
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4191103TB0200X, 103TM1800X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities