Provider Demographics
NPI:1598406209
Name:LANDRETH, VICKY LYNN
Entity Type:Individual
Prefix:
First Name:VICKY
Middle Name:LYNN
Last Name:LANDRETH
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 1:828 CATALPA PL
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-1307
Mailing Address - Country:US
Mailing Address - Phone:937-707-9040
Mailing Address - Fax:
Practice Address - Street 1:828 CATALPA PL
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-1307
Practice Address - Country:US
Practice Address - Phone:937-707-9040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2862335385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child