Provider Demographics
NPI:1851786529
Name:LANDERS PSYCHOTHERAPY SERVICES LLC
Entity Type:Organization
Organization Name:LANDERS PSYCHOTHERAPY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, CSAC
Authorized Official - Phone:262-408-0588
Mailing Address - Street 1:15460 W CAPITOL DR STE 222
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-2632
Mailing Address - Country:US
Mailing Address - Phone:262-408-0588
Mailing Address - Fax:262-599-8119
Practice Address - Street 1:15460 W CAPITOL DR STE 222
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-2632
Practice Address - Country:US
Practice Address - Phone:262-408-0588
Practice Address - Fax:262-599-8119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-31
Last Update Date:2020-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6864123101YA0400X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty