Healthcare Provider Details

I. General information

NPI: 1619093564
Provider Name (Legal Business Name): MR. JOHN WILLIAM LANDRUM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 ALEX DR
CHICKAMAUGA GA
30707-4154
US

IV. Provider business mailing address

5217 CHERYL LN # B
CHATTANOOGA TN
37415-1833
US

V. Phone/Fax

Practice location:
  • Phone: 706-539-2228
  • Fax:
Mailing address:
  • Phone: 423-877-4178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC004318
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: