Healthcare Provider Details

I. General information

NPI: 1558825398
Provider Name (Legal Business Name): LANDEN WILLIAM WINN MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2019
Last Update Date: 07/13/2023
Certification Date: 07/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BULL ST STE 200
SAVANNAH GA
31401-3378
US

IV. Provider business mailing address

3020I PROSPERITY CHURCH RD # 247
CHARLOTTE NC
28269-8112
US

V. Phone/Fax

Practice location:
  • Phone: 931-288-2422
  • Fax:
Mailing address:
  • Phone: 801-437-0490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-61390
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: