Provider Demographics
NPI:1386288777
Name:LANDRY, GRANT RICHARD
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:RICHARD
Last Name:LANDRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:766 YGNACIO WOODS CT
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94518-2200
Mailing Address - Country:US
Mailing Address - Phone:925-698-2086
Mailing Address - Fax:
Practice Address - Street 1:677 CLIFFSIDE DR
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-2957
Practice Address - Country:US
Practice Address - Phone:626-345-6455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-30
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst