Provider Demographics
NPI:1093836454
Name:LANDIS, JAMES DARRELL (MA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:DARRELL
Last Name:LANDIS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:DARRELL
Other - Middle Name:
Other - Last Name:LANDIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:132 S PUBLIC SQ
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-2434
Mailing Address - Country:US
Mailing Address - Phone:270-651-5246
Mailing Address - Fax:270-651-1965
Practice Address - Street 1:132 S PUBLIC SQ
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-2434
Practice Address - Country:US
Practice Address - Phone:270-651-5246
Practice Address - Fax:270-651-1965
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0609106H00000X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)