Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | PSY004572 | GA |
Y | 103TC0700X | Clinical Psychologist | PSY004572 | GA |
NPI | 1003569989 |
---|---|
Provider Name | Brandon Landry |
First Address | Lawrenceville, GA 30043-7531 |
Second Address | Duluth, GA 30097-4446 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/01/2022 |
Last Update Date | 31/01/2022 |