Provider Demographics
NPI:1972507457
Name:LANDSVERK, ALICIA M (PHD, LSCSW)
Entity Type:Individual
Prefix:DR
First Name:ALICIA
Middle Name:M
Last Name:LANDSVERK
Suffix:
Gender:F
Credentials:PHD, LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 E OSAGE RD STE 300
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-2290
Mailing Address - Country:US
Mailing Address - Phone:316-788-1907
Mailing Address - Fax:316-788-1941
Practice Address - Street 1:1721 E OSAGE RD
Practice Address - Street 2:STE 300
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-2092
Practice Address - Country:US
Practice Address - Phone:316-788-1907
Practice Address - Fax:316-788-1941
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100004880BMedicaid
KS100004880BMedicaid
R76394Medicare UPIN