Provider Demographics
NPI:1235773144
Name:LANDRUM, MONIQUE (LAC)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:LANDRUM
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7030 E CAMINO TENERIFE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-4125
Mailing Address - Country:US
Mailing Address - Phone:520-481-8224
Mailing Address - Fax:
Practice Address - Street 1:3045 N 1ST AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-2560
Practice Address - Country:US
Practice Address - Phone:520-505-1971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18427101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty