Provider Demographics
NPI:1417231556
Name:LANDIS, LEAH (LCSW)
Entity Type:Individual
Prefix:MISS
First Name:LEAH
Middle Name:
Last Name:LANDIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10527 POMPEY WAY
Mailing Address - Street 2:
Mailing Address - City:NORTHGLENN
Mailing Address - State:CO
Mailing Address - Zip Code:80234-3745
Mailing Address - Country:US
Mailing Address - Phone:618-521-5529
Mailing Address - Fax:
Practice Address - Street 1:1307 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1139
Practice Address - Country:US
Practice Address - Phone:618-997-5336
Practice Address - Fax:618-993-2969
Is Sole Proprietor?:No
Enumeration Date:2011-10-07
Last Update Date:2021-11-22
Deactivation Date:2021-10-13
Deactivation Code:
Reactivation Date:2021-11-22
Provider Licenses
StateLicense IDTaxonomies
COCSW.09923936104100000X
IL150.013307101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health