Provider Demographics
NPI:1558825398
Name:WINN, LANDEN WILLIAM (MA)
Entity type:Individual
Prefix:
First Name:LANDEN
Middle Name:WILLIAM
Last Name:WINN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020I PROSPERITY CHURCH RD # 247
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-8112
Mailing Address - Country:US
Mailing Address - Phone:801-437-0490
Mailing Address - Fax:
Practice Address - Street 1:100 BULL ST STE 200
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31401-3378
Practice Address - Country:US
Practice Address - Phone:931-288-2422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-25
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
UT1-22-61390103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty