Provider Demographics
NPI:1891122628
Name:LANDRY, JOHN T
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:T
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 1:5325 GRAND AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-1358
Mailing Address - Country:US
Mailing Address - Phone:612-226-2785
Mailing Address - Fax:
Practice Address - Street 1:5325 GRAND AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55419-1358
Practice Address - Country:US
Practice Address - Phone:612-226-2785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-11
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2942103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling