Provider Demographics
NPI:1831377787
Name:LANDERO, JULIO C (LISAC)
Entity type:Individual
Prefix:
First Name:JULIO
Middle Name:C
Last Name:LANDERO
Suffix:
Gender:M
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 HIWAY 95
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-7860
Mailing Address - Country:US
Mailing Address - Phone:888-459-1600
Mailing Address - Fax:928-763-3753
Practice Address - Street 1:3003 HIWAY 95
Practice Address - Street 2:SUITE 104
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7860
Practice Address - Country:US
Practice Address - Phone:888-459-1600
Practice Address - Fax:928-763-3753
Is Sole Proprietor?:No
Enumeration Date:2008-02-02
Last Update Date:2008-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1697101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ20715OtherICADC
AZ1697OtherLISAC
AZ0189OtherDOT/SAP