Provider Demographics
NPI:1003569989
Name:LANDRY, BRANDON (PSYD)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:LANDRY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1686 DUNTON GREEN WAY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-7531
Mailing Address - Country:US
Mailing Address - Phone:239-247-4699
Mailing Address - Fax:
Practice Address - Street 1:10475 MEDLOCK BRIDGE RD STE 205
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-4446
Practice Address - Country:US
Practice Address - Phone:678-379-3781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY004572103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty