Provider Demographics
NPI:1558869164
Name:LANDSTROM, SHERYL LYNN
Entity Type:Individual
Prefix:
First Name:SHERYL
Middle Name:LYNN
Last Name:LANDSTROM
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 1:13116 NE 132ND ST
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-2306
Mailing Address - Country:US
Mailing Address - Phone:425-869-6490
Mailing Address - Fax:
Practice Address - Street 1:7972 MAPLE AVE SE
Practice Address - Street 2:
Practice Address - City:SNOQUALMIE
Practice Address - State:WA
Practice Address - Zip Code:98065
Practice Address - Country:US
Practice Address - Phone:425-292-0743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60830915101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACG60830915OtherCOUNSELOR AGENCY AFFILIATED REGISTRATION