Healthcare Provider Details

I. General information

NPI: 1033627963
Provider Name (Legal Business Name): JAN MICHAEL LLANDA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2018
Last Update Date: 02/16/2021
Certification Date: 02/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 STONEBRIDGE PLAZA AVE
NORTH CHESTERFIELD VA
23225-6972
US

IV. Provider business mailing address

221 STONEBRIDGE PLAZA AVE
NORTH CHESTERFIELD VA
23225-6972
US

V. Phone/Fax

Practice location:
  • Phone: 804-378-6141
  • Fax:
Mailing address:
  • Phone: 804-378-6141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: