Provider Demographics
NPI:1386706109
Name:LANDRE, CONNIE D (LCPC)
Entity type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:D
Last Name:LANDRE
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635 W 1ST ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-1883
Mailing Address - Country:US
Mailing Address - Phone:618-530-2135
Mailing Address - Fax:
Practice Address - Street 1:1635 W 1ST ST
Practice Address - Street 2:SUITE 108
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-1883
Practice Address - Country:US
Practice Address - Phone:618-530-2135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional