Provider Demographics
NPI:1104342377
Name:LANDIS, COURTNEY
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:LANDIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 S PAINT ST
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-3202
Mailing Address - Country:US
Mailing Address - Phone:740-888-1377
Mailing Address - Fax:740-279-2970
Practice Address - Street 1:18 S PAINT ST
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601
Practice Address - Country:US
Practice Address - Phone:740-888-1377
Practice Address - Fax:740-279-2970
Is Sole Proprietor?:No
Enumeration Date:2017-08-18
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH150321101YA0400X
OHCDCA.150321101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH027027Medicaid