Provider Demographics
NPI:1902084411
Name:LANDIKUSIC, LILLY (LMFT)
Entity Type:Individual
Prefix:
First Name:LILLY
Middle Name:
Last Name:LANDIKUSIC
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12842
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84412-2842
Mailing Address - Country:US
Mailing Address - Phone:801-695-1316
Mailing Address - Fax:
Practice Address - Street 1:75 E FORT UNION BLVD STE 135
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-1531
Practice Address - Country:US
Practice Address - Phone:801-603-2547
Practice Address - Fax:801-649-0964
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT326490-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist