Provider Demographics
NPI:1437664026
Name:LANDUYT, STACEY ANN
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:ANN
Last Name:LANDUYT
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 1:2448 DAWNLIGHT AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43211-1934
Mailing Address - Country:US
Mailing Address - Phone:614-476-2900
Mailing Address - Fax:
Practice Address - Street 1:2448 DAWNLIGHT AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43211-1934
Practice Address - Country:US
Practice Address - Phone:614-476-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-05
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1601057104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker