Provider Demographics
NPI:1083284392
Name:LANDRETH, LISA MCDEVITT
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MCDEVITT
Last Name:LANDRETH
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 1:138 N CAROLINE AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-2904
Mailing Address - Country:US
Mailing Address - Phone:630-935-7916
Mailing Address - Fax:630-787-0484
Practice Address - Street 1:138 N CAROLINE AVE
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-2904
Practice Address - Country:US
Practice Address - Phone:630-935-7916
Practice Address - Fax:630-787-0484
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist