Basic Information
| Provider Information | |||||||||
| NPI: | 1851329312 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANDIS | ||||||||
| FirstName: | JANICE | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 JEFFREY CIR | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017301520 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 246 WALNUT ST | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | NEWTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024601689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172443322 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | P07387 | 01 | MA | BCBS OF MA | OTHER | 1854658 | 05 | MA | MEDICAID |