Healthcare Provider Details

I. General information

NPI: 1760396212
Provider Name (Legal Business Name): LANDYN A HOLDER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3717 EMBARCADERO ST
WATERFORD MI
48329-2242
US

IV. Provider business mailing address

3717 EMBARCADERO ST
WATERFORD MI
48329-2242
US

V. Phone/Fax

Practice location:
  • Phone: 248-707-9902
  • Fax:
Mailing address:
  • Phone: 248-707-9902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226000000X
TaxonomyRecreational Therapist Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: