Provider Demographics
NPI:1922768670
Name:LANDWEHR, LILY OLISSA
Entity Type:Individual
Prefix:
First Name:LILY
Middle Name:OLISSA
Last Name:LANDWEHR
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 1:16485 N STADIUM WAY UNIT 2091
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-4387
Mailing Address - Country:US
Mailing Address - Phone:260-440-6693
Mailing Address - Fax:
Practice Address - Street 1:13601 N LITCHFIELD RD STE 124
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85379-4260
Practice Address - Country:US
Practice Address - Phone:623-322-8250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-22
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP13328235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist