Provider Demographics
NPI:1174272173
Name:LANDRIAN, MANUEL
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:
Last Name:LANDRIAN
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 1:14931 SW 60TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-2788
Mailing Address - Country:US
Mailing Address - Phone:305-763-0539
Mailing Address - Fax:
Practice Address - Street 1:14931 SW 60TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-2788
Practice Address - Country:US
Practice Address - Phone:305-763-0539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-18
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-202627106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician