Provider Demographics
NPI:1881736916
Name:LANDES, RANDY GENE JR
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:GENE
Last Name:LANDES
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RT. 1 BOX 383 A
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:WV
Mailing Address - Zip Code:26426
Mailing Address - Country:US
Mailing Address - Phone:130-478-2148
Mailing Address - Fax:
Practice Address - Street 1:1MEDICAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301
Practice Address - Country:US
Practice Address - Phone:130-462-3246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP009403181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical