Provider Demographics
NPI:1033654314
Name:LANDWEHR, NICOLE (MSW, LCSW, REAT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:LANDWEHR
Suffix:
Gender:F
Credentials:MSW, LCSW, REAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3430 MCKELVEY ROAD
Mailing Address - Street 2:STE L PMB 1322
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-1870
Mailing Address - Country:US
Mailing Address - Phone:314-324-3835
Mailing Address - Fax:314-552-7539
Practice Address - Street 1:7110 OAKLAND AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1868
Practice Address - Country:US
Practice Address - Phone:314-324-3835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-22
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20170401841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical