Provider Demographics
NPI:1245301472
Name:LANDER, BRANDI M (LCSW)
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:M
Last Name:LANDER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:BRANDI
Other - Middle Name:M
Other - Last Name:OSTERBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1107 N. BLACKHAWK BLVD
Mailing Address - Street 2:SUITE 8
Mailing Address - City:ROCKTON
Mailing Address - State:IL
Mailing Address - Zip Code:61072-1500
Mailing Address - Country:US
Mailing Address - Phone:815-519-1074
Mailing Address - Fax:815-977-5929
Practice Address - Street 1:1107 N. BLACKHAWK BLVD
Practice Address - Street 2:SUITE 8
Practice Address - City:ROCKTON
Practice Address - State:IL
Practice Address - Zip Code:61072-1500
Practice Address - Country:US
Practice Address - Phone:815-519-1074
Practice Address - Fax:815-977-5929
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149010571101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL 5794OtherMEDICARE PTAN
ILIL 5794OtherMEDICARE PTAN
ILQ07466Medicare UPIN