=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861664294
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CECILIA LAND LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2008
-----------------------------------------------------
Last Update Date | 05/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 640 BREVARD AVE STE 106
-----------------------------------------------------
City | COCOA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32922-7849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-866-0423
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 RENEE CT
-----------------------------------------------------
City | ROCKLEDGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32955-3748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-866-0423
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 076373
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 73077622
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------