Provider Demographics
NPI:1538880224
Name:LANDEEN, DYLAN MARSHALL (LCSW)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:MARSHALL
Last Name:LANDEEN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 S CHARLOTTE DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-5675
Mailing Address - Country:US
Mailing Address - Phone:208-206-7613
Mailing Address - Fax:
Practice Address - Street 1:1810 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-5072
Practice Address - Country:US
Practice Address - Phone:208-206-7613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-09
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-425521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical