Provider Demographics
NPI:1770630485
Name:LANDESMAN, CAROL J (PHD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:J
Last Name:LANDESMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8347 SE ORIENT DR
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97080-8848
Mailing Address - Country:US
Mailing Address - Phone:503-663-7767
Mailing Address - Fax:503-663-7274
Practice Address - Street 1:8347 SE ORIENT DR
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97080-8848
Practice Address - Country:US
Practice Address - Phone:503-663-7767
Practice Address - Fax:503-663-7274
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR858103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist