Provider Demographics
NPI:1215363783
Name:LANDRY, CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
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 1:1777 TAMIAMI TRL STE 201
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33948-1064
Mailing Address - Country:US
Mailing Address - Phone:941-249-4354
Mailing Address - Fax:
Practice Address - Street 1:1777 TAMIAMI TRL STE 201
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-1064
Practice Address - Country:US
Practice Address - Phone:941-249-4354
Practice Address - Fax:941-249-4356
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-17
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH16777101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health