Provider Demographics
NPI:1679876676
Name:SEALS GREEN, LANDRIA M
Entity Type:Individual
Prefix:
First Name:LANDRIA
Middle Name:M
Last Name:SEALS GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LANDRIA
Other - Middle Name:M
Other - Last Name:SEALS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:36500 FORD ROAD
Mailing Address - Street 2:#229
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185
Mailing Address - Country:US
Mailing Address - Phone:866-752-0899
Mailing Address - Fax:203-604-0602
Practice Address - Street 1:29240 BUCKINGHAM ST
Practice Address - Street 2:SUITE 5
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-4575
Practice Address - Country:US
Practice Address - Phone:866-752-0899
Practice Address - Fax:203-604-0602
Is Sole Proprietor?:No
Enumeration Date:2010-12-13
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003069235Z00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist