Provider Demographics
NPI:1962603514
Name:LANDRY, THERESA
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:
Last Name:LANDRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7501 INTERNATIONAL BLVD.
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94621
Mailing Address - Country:US
Mailing Address - Phone:510-729-8807
Mailing Address - Fax:
Practice Address - Street 1:7501 INTERNATIONAL BLVD.
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94621
Practice Address - Country:US
Practice Address - Phone:510-729-8807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2214OtherREGISTRATION NUMBER