Provider Demographics
NPI:1447399563
Name:LANDRY, THERESA MARIE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:MARIE
Last Name:LANDRY
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 1:28685 SAND ISLAND WAY
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-8983
Mailing Address - Country:US
Mailing Address - Phone:951-679-2622
Mailing Address - Fax:
Practice Address - Street 1:650 N STATE ST
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-2960
Practice Address - Country:US
Practice Address - Phone:951-791-3316
Practice Address - Fax:951-791-3333
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS167431041C0700X
MA10166501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ24794ZMedicare ID - Type Unspecified