Provider Demographics
NPI:1871168666
Name:LANDESS, JUDITH (EDD)
Entity type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:
Last Name:LANDESS
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3649 MUNICIPAL DR
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-5434
Mailing Address - Country:US
Mailing Address - Phone:815-985-7401
Mailing Address - Fax:
Practice Address - Street 1:3110 N SHEFFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6700
Practice Address - Country:US
Practice Address - Phone:630-804-9604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-24
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2419061103TS0200X, 103TS0200X
IL11255103G00000X
103TM1800X, 103TP2701X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No252Y00000XAgenciesEarly Intervention Provider Agency