Basic Information
| Provider Information | |||||||||
| NPI: | 1740265016 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANDA | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | COSTABILE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 16310 | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284086310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107429243 | ||||||||
| FaxNumber: | 8887461787 | ||||||||
| Practice Location | |||||||||
| Address1: | 5617 MAXWELL PL | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284092966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107429243 | ||||||||
| FaxNumber: | 8887461787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2005 | ||||||||
| LastUpdateDate: | 10/28/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY22489 | CA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | PSY003722 | GA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | PSY003722 | 01 | GA | LICENSE | OTHER | 1160 | 01 | SC | SC LICENSE | OTHER |