Provider Demographics
NPI:1457648479
Name:LANDRY, ELISE
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:LANDRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 HUDSON AVE
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-1907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 HUDSON AVE
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-1907
Practice Address - Country:US
Practice Address - Phone:732-530-5584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-29
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist