Provider Demographics
NPI:1194999045
Name:LANDIS, SUZANNE A (LCSW)
Entity type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:A
Last Name:LANDIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:SUZANNE
Other - Middle Name:L
Other - Last Name:GOLDSTEIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:9307 OLD BONHOMME RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-4310
Mailing Address - Country:US
Mailing Address - Phone:314-570-7720
Mailing Address - Fax:
Practice Address - Street 1:100 SELMA AVE
Practice Address - Street 2:
Practice Address - City:WEBSTER GROVES
Practice Address - State:MO
Practice Address - Zip Code:63119-3107
Practice Address - Country:US
Practice Address - Phone:314-918-4281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000148174101YM0800X, 101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1194999045Medicaid