Provider Demographics
NPI:1942790175
Name:LANDERER, LISA MARIE (CPRSS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:LANDERER
Suffix:
Gender:F
Credentials:CPRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 N BARRON ST
Mailing Address - Street 2:
Mailing Address - City:EATON
Mailing Address - State:OH
Mailing Address - Zip Code:45320-1704
Mailing Address - Country:US
Mailing Address - Phone:937-456-7694
Mailing Address - Fax:
Practice Address - Street 1:228 N BARRON ST
Practice Address - Street 2:
Practice Address - City:EATON
Practice Address - State:OH
Practice Address - Zip Code:45320-1704
Practice Address - Country:US
Practice Address - Phone:937-456-7694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-14
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH00600175T00000X
OHCDCA170872101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH00600OtherOHIO MENTAL HEALTH AND ADDICTION SERVICES