Provider Demographics
NPI:1730820499
Name:LANDES, TREVYN (BA)
Entity type:Individual
Prefix:MS
First Name:TREVYN
Middle Name:
Last Name:LANDES
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3416 THOMAS AVE
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-4117
Mailing Address - Country:US
Mailing Address - Phone:618-550-2037
Mailing Address - Fax:
Practice Address - Street 1:3416 THOMAS AVE
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-4117
Practice Address - Country:US
Practice Address - Phone:618-550-2037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)