Provider Demographics
NPI:1023327525
Name:LANDRY, IJUANA (LAPC)
Entity type:Individual
Prefix:
First Name:IJUANA
Middle Name:
Last Name:LANDRY
Suffix:
Gender:F
Credentials:LAPC
Other - Prefix:
Other - First Name:IJUANA
Other - Middle Name:
Other - Last Name:MCCAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAPC
Mailing Address - Street 1:3550 CENTERVILLE HWY
Mailing Address - Street 2:107 #120
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-4133
Mailing Address - Country:US
Mailing Address - Phone:404-314-5259
Mailing Address - Fax:
Practice Address - Street 1:317 W HILL ST
Practice Address - Street 2:205
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-4367
Practice Address - Country:US
Practice Address - Phone:404-314-5259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC002276101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional