Healthcare Provider Details

I. General information

NPI: 1053414391
Provider Name (Legal Business Name): STACY LEE LANDESBERG M.ED., PCC-S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 08/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 ALBERT SABIN WAY
CINCINNATI OH
45229-2838
US

IV. Provider business mailing address

8323 ARBORCREST DR
CINCINNATI OH
45236-1403
US

V. Phone/Fax

Practice location:
  • Phone: 513-558-6649
  • Fax: 513-558-3100
Mailing address:
  • Phone: 513-792-0160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE3969
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: