Provider Demographics
NPI:1154837318
Name:LANDEROS, HEATHER IRBY
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:IRBY
Last Name:LANDEROS
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 1:7788 TEAL DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-5431
Mailing Address - Country:US
Mailing Address - Phone:817-296-1742
Mailing Address - Fax:
Practice Address - Street 1:1870 RUFE SNOW DR
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-5629
Practice Address - Country:US
Practice Address - Phone:817-296-4917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-22
Last Update Date:2017-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67231101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional