Healthcare Provider Details

I. General information

NPI: 1992130108
Provider Name (Legal Business Name): ROBERT W LANDRY PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2013
Last Update Date: 09/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 HWY. 104
IONE CA
95640
US

IV. Provider business mailing address

PO BOX 409099 MENTAL HEALTH SERVICES
IONE CA
95640
US

V. Phone/Fax

Practice location:
  • Phone: 209-274-4911
  • Fax: 209-274-5147
Mailing address:
  • Phone: 209-274-4911
  • Fax: 209-274-5147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY 18311
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: