MEDICARE: STEPHEN KING LANDER LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LMFT #834	MN
2	101YM0800X	Mental Health Counselor	MA LP #3316	MN
3	101YM0800X	Mental Health Counselor	20572	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	41-1836968	OTHER		FED TAX ID

General Provider Information

NPI Number	:	1063560365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHEN KING LANDER LMFT

Provider Business Mailing Address
First Line	:	796 N SEVILLE CIR
Second Line	:
City	:	PALM SPRINGS
State	:	CA
Zip	:	92262-6242
Country	:	US
Telephone Number	:	612-205-4576
Fax Number	:

Provider Business Practice Location Address
First Line	:	71687 HIGHWAY 111 STE 205
Second Line	:
City	:	RANCHO MIRAGE
State	:	CA
Zip	:	92270-4515
Country	:	US
Telephone Number	:	612-205-4576
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/05/2007
Last Update Date	:	03/10/2021

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