Provider Demographics
NPI:1972919561
Name:LANDRON, MARJORIE VIELKA (LSW)
Entity type:Individual
Prefix:
First Name:MARJORIE
Middle Name:VIELKA
Last Name:LANDRON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 MULBERRY BUSH CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-9208
Mailing Address - Country:US
Mailing Address - Phone:702-305-5188
Mailing Address - Fax:
Practice Address - Street 1:918 MULBERRY BUSH CT
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-9208
Practice Address - Country:US
Practice Address - Phone:702-305-5188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-03
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8054-C1041C0700X
FLSW206461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV460732507Medicaid