MEDICARE: MR. KRISTOPHER ERNEST LANDERS LLMSW

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	1041C0700X	Clinical Social Worker	6801103491	MI
2	104100000X	Social Worker	6801103491	MI

General Provider Information

NPI Number	:	1700352036
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KRISTOPHER ERNEST LANDERS LLMSW

Provider Business Mailing Address
First Line	:	19359 HOUGHTON ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48219-1825
Country	:	US
Telephone Number	:	313-409-5616
Fax Number	:

Provider Business Practice Location Address
First Line	:	19359 HOUGHTON ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48219-1825
Country	:	US
Telephone Number	:	313-409-5616
Fax Number	:

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

Provider Enumeration Date	:	10/14/2018
Last Update Date	:	10/14/2018

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