Provider Demographics
NPI:1720740947
Name:LANDHOLM, TAYLOR (OT)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:LANDHOLM
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 S LAKEPORT ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51106-4222
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3100 S LAKEPORT ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106-4222
Practice Address - Country:US
Practice Address - Phone:712-277-4442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1106362081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine