Provider Demographics
NPI:1679093900
Name:LANDIS, ELLEN MARIE
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:MARIE
Last Name:LANDIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6504 NE 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-3619
Mailing Address - Country:US
Mailing Address - Phone:949-933-3491
Mailing Address - Fax:
Practice Address - Street 1:7319 N JOHN AVE STE 101
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203
Practice Address - Country:US
Practice Address - Phone:503-489-8789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist