Provider Demographics
NPI:1801463310
Name:LANDON, WINIFRED ROSE (LSW)
Entity type:Individual
Prefix:
First Name:WINIFRED
Middle Name:ROSE
Last Name:LANDON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2353 W 18TH PL APT 3R
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-2560
Mailing Address - Country:US
Mailing Address - Phone:630-779-0767
Mailing Address - Fax:
Practice Address - Street 1:2045 W NORTH AVE STE 2A
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-5413
Practice Address - Country:US
Practice Address - Phone:773-340-0203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.104588104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker