Basic Information
| Provider Information | |||||||||
| NPI: | 1790872612 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LANDIS | ||||||||
| FirstName: | JODIE | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MS, CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 889 RIVERVIEW DR | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265054631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045992485 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1085 VAN VOORHIS RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265053497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045999250 | ||||||||
| FaxNumber: | 3045999254 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SLP-0624 | WV | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 9400050-0000 | 05 | WV | MEDICAID |