Provider Demographics
NPI:1972617173
Name:LANDEAU, KENNETH WALLACE (COTA/L)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:WALLACE
Last Name:LANDEAU
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:394 TOWNLINE RD
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-1424
Mailing Address - Country:US
Mailing Address - Phone:631-499-4661
Mailing Address - Fax:
Practice Address - Street 1:120 PLANT AVE
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-3805
Practice Address - Country:US
Practice Address - Phone:631-851-3810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005537-1251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services