Provider Demographics
NPI:1720574197
Name:LANDRY, DEREK (OT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:LANDRY
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49222 GEDDES RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-2204
Mailing Address - Country:US
Mailing Address - Phone:248-330-7163
Mailing Address - Fax:
Practice Address - Street 1:4427 VENOY RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-1871
Practice Address - Country:US
Practice Address - Phone:734-729-4436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201008526225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist