MEDICARE: HEATHER LAND

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1316892755
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER LAND

Provider Business Mailing Address
First Line	:	1215 SHASTA WAY
Second Line	:
City	:	SHASTA LAKE
State	:	CA
Zip	:	96019-9710
Country	:	US
Telephone Number	:	619-261-8020
Fax Number	:

Provider Business Practice Location Address
First Line	:	1215 SHASTA WAY
Second Line	:
City	:	SHASTA LAKE
State	:	CA
Zip	:	96019-9710
Country	:	US
Telephone Number	:	619-261-8020
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/02/2026
Last Update Date	:	03/02/2026

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Directions to “ HEATHER LAND ” Practice Location

Language	Start Address	Practice Location

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