Healthcare Provider Details

I. General information

NPI: 1164090601
Provider Name (Legal Business Name): ELIZABETH DIANNE LANDRY MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2021
Last Update Date: 06/11/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 BROADWAY 1ST FLOOR
SEATTLE WA
98122
US

IV. Provider business mailing address

325 9TH AVE # MS 359797
SEATTLE WA
98104-2420
US

V. Phone/Fax

Practice location:
  • Phone: 965-720-6744
  • Fax:
Mailing address:
  • Phone: 206-744-9657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: