Healthcare Provider Details

I. General information

NPI: 1780331561
Provider Name (Legal Business Name): JOSHUA RYAN LANDIS PEER RECOVERY SUPPOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2022
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551 1/2 E MAIN ST
LANCASTER OH
43130-3809
US

IV. Provider business mailing address

PO BOX 243
SUGAR GROVE OH
43155-0243
US

V. Phone/Fax

Practice location:
  • Phone: 614-404-6008
  • Fax: 740-277-7790
Mailing address:
  • Phone: 614-404-6008
  • Fax: 740-277-7790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number0002872
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: