Healthcare Provider Details

I. General information

NPI: 1104915669
Provider Name (Legal Business Name): CLARISSE LANDRY PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 SW HIGGINS AVE STE 205
MISSOULA MT
59803-1340
US

IV. Provider business mailing address

420 WOODFORD ST
MISSOULA MT
59801-4044
US

V. Phone/Fax

Practice location:
  • Phone: 406-721-3096
  • Fax: 406-721-3956
Mailing address:
  • Phone: 406-721-3096
  • Fax: 406-721-3956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number122PT
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: