Provider Demographics
NPI:1992811913
Name:LANDIS, RICHARD ELLIOT (PHD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ELLIOT
Last Name:LANDIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30101 TOWN CENTER DRIVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-5028
Mailing Address - Country:US
Mailing Address - Phone:949-495-1164
Mailing Address - Fax:949-249-5681
Practice Address - Street 1:30101 TOWN CENTER DR
Practice Address - Street 2:SUITE 201
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-5028
Practice Address - Country:US
Practice Address - Phone:949-495-1164
Practice Address - Fax:949-249-5681
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5814103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARLCP PSY5814Medicare ID - Type Unspecified