Provider Demographics
NPI:1164639191
Name:LANDRY, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LANDRY
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 1:62 CLUBHOUSE DR
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:CT
Mailing Address - Zip Code:06416-2564
Mailing Address - Country:US
Mailing Address - Phone:860-632-7190
Mailing Address - Fax:
Practice Address - Street 1:21 HYDE PARK RD
Practice Address - Street 2:
Practice Address - City:STAFFORD SPRINGS
Practice Address - State:CT
Practice Address - Zip Code:06076-1507
Practice Address - Country:US
Practice Address - Phone:860-684-4239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist