Provider Demographics
NPI:1376905315
Name:LANDIS, NICOLE ELIZABETH (LMFT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:LANDIS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2564 NE COURTNEY DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7638
Mailing Address - Country:US
Mailing Address - Phone:541-678-5277
Mailing Address - Fax:541-678-5280
Practice Address - Street 1:2564 NE COURTNEY DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-7638
Practice Address - Country:US
Practice Address - Phone:541-678-5277
Practice Address - Fax:541-678-5280
Is Sole Proprietor?:No
Enumeration Date:2016-03-28
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT1706106H00000X
WACG60306395101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor