Provider Demographics
NPI:1255182606
Name:LANDIS, AXELLE EMMANUELLE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:AXELLE
Middle Name:EMMANUELLE
Last Name:LANDIS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6333 E MENSER AVE
Mailing Address - Street 2:
Mailing Address - City:ATHOL
Mailing Address - State:ID
Mailing Address - Zip Code:83801-9426
Mailing Address - Country:US
Mailing Address - Phone:208-683-2231
Mailing Address - Fax:
Practice Address - Street 1:6333 E MENSER AVE
Practice Address - Street 2:
Practice Address - City:ATHOL
Practice Address - State:ID
Practice Address - Zip Code:83801-9426
Practice Address - Country:US
Practice Address - Phone:208-683-2231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INSLP-5316235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist