Healthcare Provider Details

I. General information

NPI: 1679876676
Provider Name (Legal Business Name): LANDRIA M SEALS GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LANDRIA M SEALS CCC-SLP

II. Dates (important events)

Enumeration Date: 12/13/2010
Last Update Date: 01/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29240 BUCKINGHAM ST SUITE 5
LIVONIA MI
48154-4575
US

IV. Provider business mailing address

36500 FORD ROAD #229
WESTLAND MI
48185
US

V. Phone/Fax

Practice location:
  • Phone: 866-752-0899
  • Fax: 203-604-0602
Mailing address:
  • Phone: 866-752-0899
  • Fax: 203-604-0602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number003069
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: