Provider Demographics
NPI:1710460274
Name:LANDRY, ALLISEN (PSYD)
Entity Type:Individual
Prefix:
First Name:ALLISEN
Middle Name:
Last Name:LANDRY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 CHILDREN'S DRIVE
Mailing Address - Street 2:DEPARTMENT OF PSYCHOLOGY
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205
Mailing Address - Country:US
Mailing Address - Phone:614-722-4700
Mailing Address - Fax:614-722-4718
Practice Address - Street 1:2310 130TH AVE NE APT 1524
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-1799
Practice Address - Country:US
Practice Address - Phone:206-627-0109
Practice Address - Fax:614-722-4718
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
WAPY61049964103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1473276Medicaid