Provider Demographics
NPI:1689828139
Name:LANDHERR, KEITH SCOTT (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:SCOTT
Last Name:LANDHERR
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 JOHNSON AVE
Mailing Address - Street 2:#1-C
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-6464
Mailing Address - Country:US
Mailing Address - Phone:718-601-3629
Mailing Address - Fax:718-601-3629
Practice Address - Street 1:2400 JOHNSON AVE
Practice Address - Street 2:#1-C
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-6464
Practice Address - Country:US
Practice Address - Phone:718-601-3629
Practice Address - Fax:718-601-3629
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-11
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY05789172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05789OtherNYS LICENSE# 5789