Healthcare Provider Details

I. General information

NPI: 1821712712
Provider Name (Legal Business Name): CECILIA LAND LCSW-R
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 BREVARD AVE
COCOA FL
32922-7849
US

IV. Provider business mailing address

15 RENEE CT
ROCKLEDGE FL
32955-3748
US

V. Phone/Fax

Practice location:
  • Phone: 347-866-0423
  • Fax:
Mailing address:
  • Phone: 347-866-0423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1861664294
Identifier TypeOTHER
Identifier State
Identifier IssuerNPI

VIII. Authorized Official

Name: CECILIA MICHELLE PAPALAS LAND
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential:
Phone: 347-866-0423