Provider Demographics
NPI:1265571319
Name:LANDROCK, MARY JANE JANE (LCSW)
Entity type:Individual
Prefix:
First Name:MARY JANE
Middle Name:JANE
Last Name:LANDROCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1719 FORD AVENUE
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-2714
Mailing Address - Country:US
Mailing Address - Phone:310-374-7347
Mailing Address - Fax:
Practice Address - Street 1:1719 FORD AVENUE
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90278-2714
Practice Address - Country:US
Practice Address - Phone:310-373-0527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASW9480101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SW9480Medicare ID - Type Unspecified