Healthcare Provider Details

I. General information

NPI: 1023269388
Provider Name (Legal Business Name): CLIFFORD ROSS LANDIS LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2008
Last Update Date: 07/22/2021
Certification Date: 07/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

518 S SCHOOL ST # 205
UKIAH CA
95482-5479
US

IV. Provider business mailing address

518 S SCHOOL ST # 205
UKIAH CA
95482-5479
US

V. Phone/Fax

Practice location:
  • Phone: 707-472-2317
  • Fax: 707-900-8192
Mailing address:
  • Phone: 707-380-9407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number44568
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: