Provider Demographics
NPI:1447755582
Name:LANDRE, RICK THOMAS (MS)
Entity Type:Individual
Prefix:
First Name:RICK
Middle Name:THOMAS
Last Name:LANDRE
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10815 RUDOLPH CT
Mailing Address - Street 2:
Mailing Address - City:SPRING GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60081-9657
Mailing Address - Country:US
Mailing Address - Phone:815-793-1055
Mailing Address - Fax:
Practice Address - Street 1:5400 W ELM ST STE 104
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-4032
Practice Address - Country:US
Practice Address - Phone:815-331-8768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist