Provider Demographics
NPI:1104367945
Name:LANDRUM, TYREE
Entity Type:Individual
Prefix:
First Name:TYREE
Middle Name:
Last Name:LANDRUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13428 MAXELLA AVE STE 913
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-5620
Mailing Address - Country:US
Mailing Address - Phone:424-272-5238
Mailing Address - Fax:323-417-4900
Practice Address - Street 1:13428 MAXELLA AVE STE 913
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-5620
Practice Address - Country:US
Practice Address - Phone:424-272-5238
Practice Address - Fax:323-417-4900
Is Sole Proprietor?:No
Enumeration Date:2017-03-13
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA472883245OtherTAX ID