Provider Demographics
NPI:1255173621
Name:LANDRUM, MADDIE BELLE (CSW)
Entity type:Individual
Prefix:
First Name:MADDIE
Middle Name:BELLE
Last Name:LANDRUM
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1693 N 400 W APT B204
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-1989
Mailing Address - Country:US
Mailing Address - Phone:208-260-0893
Mailing Address - Fax:
Practice Address - Street 1:15 GOLF COURSE ROAD SUITE E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321
Practice Address - Country:US
Practice Address - Phone:435-799-5035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-07
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13994044-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical