Provider Demographics
NPI:1164005682
Name:MISERY LANDE THERAPEUTIC SERVICES
Entity type:Organization
Organization Name:MISERY LANDE THERAPEUTIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:EBONI
Authorized Official - Middle Name:
Authorized Official - Last Name:VINSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:757-525-2697
Mailing Address - Street 1:677 TECH CENTER PKWY APT 1420
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-1555
Mailing Address - Country:US
Mailing Address - Phone:757-525-2697
Mailing Address - Fax:
Practice Address - Street 1:677 TECH CENTER PKWY APT 1420
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-1555
Practice Address - Country:US
Practice Address - Phone:757-525-2697
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-03
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty