Provider Demographics
NPI:1891493516
Name:LANDRY, OLIVIA GRACE (LCSW)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:GRACE
Last Name:LANDRY
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 1:4316 ARSENAL ST UNIT 1F
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-1913
Mailing Address - Country:US
Mailing Address - Phone:318-272-1609
Mailing Address - Fax:
Practice Address - Street 1:700 E 61ST ST UNIT 377761
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-5297
Practice Address - Country:US
Practice Address - Phone:847-905-6250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-21
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150109015104100000X
IL1490273551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker